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RC601  .R71  Manual  of  psychiatry 


RECAP 


MANUAL 

OF 

PSYCHIATRY 


EDITED  BY 

AARON  J.  ROSANOFF,  M.D. 

Clinical  Director,   Kings  Park  State  Hospital,  N.  Y. 

Lieutenant  Colonel,  Officers'  Section,  Medical  Reserve  Corps, 

U.  S.  Army 


FIFTH  EDITION.    REVISED  AND  ENLARGED 


NEW  YORK 
JOHN  WILEY  &  SONS,   Inc. 
London:  CHAPMAN  &   HALL,   Limited 
1920 


CoPTBiGHT,  1905,  1908,  1911,  1916,  1920, 

BT 

A.  J.  ROSANOFF 


PRESS    OF 

BHAUNWORTH    &    CO. 

BOOK    MANUFACTURERS 

BROOKLYN.    N.    Y. 


LIST   OF   CONTRIBUTORS 


J.  Rogues  de  Fursac,  M.D.,  formerly  Chief  of  Clinic  at  the  Medical 
Faculty  of  Paris,  Physician  in  Chief  of  the  Public  Insane  Asylums  of 
the  Seine  Department. 

Chapters  or  sections  dealing  with  symptomatology,  general 
therapeutic  indications,  epilepsy,  dementia  praecox,  paranoia, 
manic-depressive  psychoses,  involutional  melanchoha,  acute 
and  chronic  alcoholism,  drug  addictions,  genera'  paralysis, 
deliria  of  infectious  origin,  psychoses  of  exhaustion,  ursemic 
delirium,  myxoedema  and  cretinism,  and  senile  dementia. 

Aaron  J.  Rosanofp,  M.D.,  Clinical  Director,  Kings  Park  State 
Hospital,  N.  Y.,  Lieutenant  Colonel,  Medical  Section,  OfEcei-s'  Reserve 
Corps,  U.  S.  Army. 

General  editorial  responsibility;  also  chapters,  sections,  or 
appendices  dealing  with  etiology,  history  taking,  methods  of 
examination,  special  diagnostic  procedures,  psychotherapy,  psy- 
choanalysis, prognosis,  prevalence  of  mental  disorders,  pro- 
phylaxis, medico-legal  questions,  extramm-al  psychiatry,  arrests 
of  development,  constitutional  psychopathic  states,  psychoneu- 
roses,  Huntington's  chorea,  cerebro-spinal  syphHis,  cerebral 
arteriosclerosis,  traumatic  psychoses,  hyperthyroidism,  organic 
cerebral  affections,  Wassermann  reaction,  association  test. 

H.  L.  HoLLiNGWORTH,  Ph.D.,  Associate  Professor  of  Psychology, 
Columbia  University. 

Chapters  or  appendices  dealing  with  applications  of  psychology 
in  psychiatry,  normal  course  of  mental  development,  and 
standard  psychological  group  tests. 

Miss  Mary  C.  Jarrett,  Associate  Director,  Smith  College  Training 
School  for  Social  Work;  formerly  Chief  of  Social  Service,  Boston 
Psychopathic  Hospital. 

Chapter  dealing  with  applications  of  sociology  in  psychiatry. 

Clarence  A.  Neymann,  M.D.,  Superintendent,  Cook  County 
Psychopathic  Hospital,  Chicago. 

Appendix  dealing  with  lumbar  puncture,  cell  count,  and  chemical 
tests  of  cerebro-spinal  fluid. 
iii 


Digitized  by  the  Internet  Arcliive 

in  2010  with  funding  from 

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http://www.archive.org/details/manualofpsychiaOOrosa 


PREFACE   TO   THE   FIFTH  EDITION 


In  the  course  of  the  World  War  unprecedented  oppor- 
tunities enabled  psychiatry  to  make  great  strides.  The 
movement  for  mental  hygiene  is  developing  direction, 
organization,  and  force.  Psychiatrists  no  longer  confine 
their  activities  within  the  walls  of  institutions  for  the  insane, 
but  are  constantly  organizing  connections  with  general 
hospitals,  schools,  charitable  organizations,  courts  of  law, 
penal  institutions,  etc. 

In  the  endeavor  to  keep  this  Manual  abreast  of  progress 
and  to  maintain  its  usefulness  to  the  student  of  psychiatry 
numerous  changes  and  additions  have  been  made  in  pre- 
paring the  present  edition. 

New  chapters,  sections,  or  appendices,  dealing  with  the 
following  subjects,  have  been  added:  applications  of  psychol- 
ogy in  psychiatry,  psychoanalysis,  applications  of  sociology 
in  psychiatry,  extramural  psychiatry,  psychoneuroses, 
hyperthyroidism,  normal  course  of  early  mental  development, 
Stanford  revision  of  the  Binet-Simon  intelligence  scale,  Kent- 
Rosanoff  association  test,  standard  psychological  group 
tests,  and  the  classification  of  mental  diseases  adopted  by  the 
American  Medico-Psychological  Association. 

The  chapters,  sections,  or  appendices,  dealing  with  the 
following  subjects,  have  been  extensively  rewritten:  arrests 
of  development,  epilepsy,  constitutional  psychopathic  states, 
chronic  alcoholism,  cerebro-spinal  syphilis,  lumbar  puncture, 
and  tests  of  the  cerebro-spinal  fluid. 

The  remaining  chapters  have  also  undergone  careful 
revision  with  resulting  numerous  minor  changes  and  addi- 
tions. 


VI  PREFACE  TO  THE  FIFTH  EDITION 

The  Index  has  been  greatly  amphfied  and,  it  is  believed, 
rendered  more  serviceable. 

Some  of  the  alterations  have  been  made  as  a  result  of 
criticisms  and  suggestions  offered  by  reviewers,  to  whom 
grateful  acknowledgment  is  hereby  made. 

In  order  to  introduce  all  the  above  mentioned  changes 
and  additions  it  proved  necessary  to  reset  the  entire  book. 
The  aim  has,  however,  been  adhered  to  of  avoiding  its 
growth  beyond  the  proportions  of  a  practical  manual,  con- 
venient for  frequent  reference.  By  the  use  of  somewhat 
smaller  type  and  by  making  the  pages  a  little  larger  the 
increase  in  thickness  has  been  kept  down  as  far  as  possible, 
although,  of  course,  it  could  not  be  wholly  avoided. 

This  Manual,  as  many  know,  first  appeared  in  English  in 
1905,  as  a  translation  of  the  French  Manuelde  Psychiatrie 
by  J.  Rogues  de  Fursac.  The  special  demands  of  American 
students  have,  through  successive  editions,  led  to  changes 
and  additions  eventually  affecting  even  scope  and  viewpoint. 
To-day  the  original  French  model  still  constitutes  the 
nucleus  around  which  this  ]\Ianual  has  grown ;  yet  it  is  but 
the  duty  of  the  American  editor  to  acknowledge  his  full 
responsibility  for  its  teachings. 

It  is  the  earnest  hope  of  the  editor  and  his  collaborators 
that  this  Manual  will  continue  to  meet  a  growing  demand, 
as,  apparently,  it  has  done  in  the  past. 

Aaron  J.  Rosanoff. 

Kings  Park,  Long  Island,  N.  Y. 
January,  1920. 


CONTENTS 


PAGE 

List  of  Contributors iii 

Preface  to  the  Fifth  Edition v 

Introduction xiii 

PART  I— GENERAL  PSYCHIATRY 

I.  Etiology 1 

Essential  causes:  heredity,  addiction  to  alcohol  or  drugs, 
syphilis,  head  injuries. — Incidental  or  contributing  causes. 
— Other  etiological  factors:  race,  age,  sex,  environment, 
occupation,  marital  condition,  education,  immigration. 

II.  Symptomatology 19 

Disorders  of  perception:  insufficiency  of  perception, 
illusions,  hallucinations;  properties  common  to  all  hallu- 
cinations; the  different  varieties  of  hallucinations;  theories 
of  hallucinations. 

III.  Symptomatology  (continued) 40 

Consciousness,  memory,  attention,  association  of  ideas, 
judgment:  unconsciousness,  clouding  of  consciousness, 
disorientation,  states  of  obscuration;  different  forms  of 
amnesia,  illusions  and  hallucinations  of  memory,  pseudo- 
reminiscences;  weakening  of  attention,  flight  of  ideas, 
incoherence,  imperative  ideas,  fixed  ideas,  autochthonous 
ideas;   false  interpretations,  delusions. 

IV.  Symptomatology  (concluded), 61 

Affectivity,  reactions,  personality:  morbid  indifference, 
exaggeration  of  affectivity,  morbid  depression,  anger,  and 
joy;  abouha,  automatic  reactions,  suggestibility,  impulsive 
reactions,  stereotypy,  negativism,  disorders  of  coenesthe- 
sia,  alterations  of  personality. 
vii 


viii  CONTENTS 

PAGB 

V.  The  Practice  op  Psychiatry 76 

History  taking:  family  history,  personal  history,  history 
of  psychosis. — Methods  of  examination:  physical  exami- 
nation, mental  examination. 

VI.  The  Practice  of  Psychiatry  (continued) 88 

Special  diagnostic  procedures:  lumbar  puncture,  Wasser- 
mann  reaction,  chemical  tests,  intelligence  tests,  examina- 
tion for  aphasia,   association  tests,  other  tests,  medical         • 
consultations. 

VII.  The  Practice  op  Psychiatry  {continued) 92 

Apphcations  of  psychology  in  psychiatry :  mental  measure- 
ments, normal  curves  of  distribution,  group  tests,  associa- 
tion tests,  experimental  psychopathology  and  pharmaco- 
psychology,  educational  therapeutics,  theoretical  relations. 

VIII.  The  Practice  of  Psychiatry  {continued) 101 

General  therapeutic  indications:  institution,  commit- 
ment ;  treatment  of  excitement,  suicidal  tendencies,  refusal 
of  food. — Psychotherapy. — Parole  and  discharge. — After- 
care. 

IX.  The  Practice  of  Psychiatry  {continued) 120 

Psychoanalysis:  realm  of  the  unconscious,  sexual  theory, 
psychopathology  of  everyday  life,  interpretation  of  dreams, 
realistic  and  autistic  thinking,  technique  of  psychoanalysis. 

X.  The  Practice  of  Psychiatry  {continued) 146 

Applications  of  sociology  in  psychiatry:  interrelation  of 
social  and  mental  disorders,  the  psychiatric  social  worker, 
functions  of  a  sociological  department,  organization  of  a 
sociological  department. 

XI.  The  Practice  of  Psychiatry  {continued) 158 

Prognosis. — Prevalence  of  mental  disorders:  are  they  on 
the  increase? 

XII.  The  Practice  of  Psychiatry  {continued) 165 

Prophylaxis  in  psychiatry:  relationship  between  bad 
heredity  and  other  causes;  prevention  of  bad  heredity; 
prevention  of  alcoholism,  drug  addictions,  and  syphilis; 
the  individual;  immigration. 


CONTENTS  ix 

PAGE 

XIII.  The  Practice  of  Psychiatry  (continued) 181 

Medico-legal  questions  in  psychiatry:  commitment; 
legal  competence;  testamentary  capacity;  criminal  re- 
sponsibility; relationship"  between  vice,  crime,  and  men- 
tal disorders. 

XIV.  The  Practice  of   Psychiatry  (concluded) 190 

Extramural  psychiatry:  community  surveys.  National 
Army  statistics. 

PART  II.  —  SPECIAL  PSYCHIATRY 

Classification 193 

I.  Arrests  of  Development 195 

Idiocy,  imbecility,  moronism  or  feeble-mindedness,  bor- 
derline conditions. 

II.  Mental  Disorders  Associated  with  Epilepsy 205 

Permanent  disorders;  paroxysmal  disorders. 

III.  Constitutional  Psychopathic  States 215 

Inadequate  personality,  paranoid  personality,  emotional 
instability,  criminalism,  pathological  lying,  sexual  psy- 
chopathy, nomadism. 

IV.  Dementia  Pi»ecox 229 

Symptoms  common  to  all  forms;  simple  form,  catatonia, 
delusional  forms,  delire  chronique  a  eoolution  systematique; 
diagnosis,  prognosis,  etiology,  nature,  pathological  anatomy, 
treatment. 

V.  Paranoia. 262 

VI.  Manic-Depressive  Psychoses 267 

Manic  types:  simple,  delusional,  confused  mania. — 
Depressed  types:  simple,  delusional,  stuporous  depres- 
sion.— Mixed  types:-  mixed  type  proper,  attacks  of  double 
form. — Course,  prognosis,  diagnosis;  homogeneity  of 
manic-depressive  psychoses;  treatment. — Chronic  mania. 

VII.  Involutional  Melancholia 292 


X  CONTENTS 

PAGE 
VIII.    PSYCHONEUKOSES 300 

Hysteria,  neurasthenia,  psychasthenia. 
IX.  Huntington's  Choeea 327 

X.  Acute  Alcoholism.    Pathological  Deunkenness  . . .     331 

XI.  Chronic  Alcoholism 335 

Permanent  symptoms:  psychic,  physical. — Diagnosis, 
prognosis,  pathological  anatomy,  etiology. — Episodic  acci- 
dents: delirium  tremens,  acute  hallucinosis,  delusional 
states,  polyneuritic  psychosis. 

XII.  Drug  Addictions 355 

Etiology,  symptoms,  course,  treatment;  cocaine  delirium. 

XIII.  Syphilitic  Disorders 364 

Mesoblastic  invasion:  cerebral  syphilis:  early  involve- 
ment, meningitic  type,  gummatous  type,  endarteritic  type. 

XIV.  Syphilitic  Disorders  (continued) 370 

Parenchymatous  invasion :  general  paralysis :  prodromal 
period,  essential  symptoms,  inconstant  symptoms,  forms, 
course,  prognosis,  diagnosis,  pathological  anatomy,  etiology, 
prevention,  treatment. 

XV.  Syphilitic  Disorders  (concluded) 405 

Cerebral  arteriosclerosis:  arterial  supply  of  the  brain; 
systemic  symptoms,  symptoms  common  to  all  forms, 
symptoms  of  occlusion  of  large  vessels,  disease  of  the  medul- 
lary system  of  terminal  arterioles,  disease  of  the  cortical 
system  of  terminal  arterioles;  diagnosis,  course,  prognosis, 
treatment. 

XVI.  Traumatic  Disorders 413 

Traumatic  delirium,  traumatic  constitution,  traumatic 
epUepsy,  traumatic  dementia. 

XVII.  Miscellaneous  Groups 419 

Deliria  of  infectious  origin. 

XVIII.  Miscellaneous  Groups  (continued) 422 

Psychoses  of  exhaustion:  primary  mental  confusion; 
acute  delirium. 


CONTENTS  xi 

PAGE 

XIX.  Miscellaneous  Groups  {continued) 429 

Psychoses  of  auto-intoxication:  uraemic  delirium. 

XX.  Miscellaneous  Groups  (continued) 431 

Thyrogenic    psychoses:     hypothyroidism:    myxoedema, 
cretinism;    hyperthyroidism:    exophthalmic  goiter. 

XXI.  Miscellaneous  Groups  (continued) 437 

Mental   disorders   due   to   organic   cerebral   affections: 
tumors,  multiple  sclerosis,  brain  abscess,  central  neuritis. 

XXII.  Miscellaneous  Groups  (concluded) 443 

Senile  dementia:    general  symptomatology,   delusional 
forms,  complications,  prognosis,  diagnosis,  treatment. 


PART  III.    APPENDICES  DEALING   WITH   TECHNIQUE   OF 
SPECIAL  DIAGNOSTIC  PROCEDURES 

I.  Lumbar  Puncture 449 

Cell  count. — Chemical  tests:  Lange's  colloidal  gold  test, 
Noguchi's  butyric  acid  test,  Ross-Jones  ammonium  sul- 
phate test,  Pandy's  phenol  test. 

II.  Wassermann  Reaction 460 

Principle  of  the  Wassermann  reaction,  preparation  of 
reagents,  collection  of  specimens  for  examination,  technique 
of  the  reaction. 

III.  Examination  for  Aphasia 470 

IV.  Normal  Course  of  Mental  Development  prom  Birth 

TO  Third  Year 474 

V.  Stanford   Revision   of   Binet-Simon   Intelligence 

Scale 476 

Materials  and  equipment;  experimental  conditions; 
range  and  order  of  testing;  scoring  and  recording;  alter- 
native tests;  mental  age;  intelligence  quotient;  instruc- 
tions for  tests  for  mental  ages  from  Year  III  to  "Superior 
Adult." 


xii  CONTENTS 

FA6II 

VI.  Free  Association  Test  (Kent-Rosanoff) 547 

Instructions,  classification  of  reactions,  norms,  frequency 
tables,  appendix  to  frequency  tables. 

VII.  Standard  Psychological  Group  Tests 621 

Digit  span,  logical  memory,   cancellation,   completion, 
opposites,  part-whole,  word  building. 

VIII.  Classification  op  Mental  Diseases  Adopted  by  the 

American  Medico-Psychological  Association  ....     625 

Main  groups  and  subdivisions;   definitions  and  explana- 
tory notes. 

Index  of  Authors 641 

Index  of  Subjects 647 


INTRODUCTION 


Psychiatry  is  that  branch  of  neurology  which  treats 
of  mental  disorders  and  of  the  organic  changes  associated 
with  them. 

Mental  disorders  arrange  themselves  in  two  funda- 
mental categories,  characterized  respectively  by  insuf- 
ficiency and  perversion  of  the  psychic  faculties. 

Insufficiency  may  be  either  congenital  or  acquired.  In 
the  first  case  it  constitutes  arrest  of  development;  in  the 
second,  psychic  paralysis.  When  the  psychic  paralysis 
is  temporary,  causing  a  suspension,  but  not  a  destruction, 
of  mental  activity,  it  is  spoken  of  as  psychic  inhibition; 
on  the  other  hand,  when  it  is  permanently  established,  it 
constitutes  mental  deterioration  or  dementia. 

Perversion  of  the  psychic  faculties  may  also  be  con- 
genital or  acquired.  Various  terms  are  applied  to  its  mani- 
festations, depending  upon  the  particular  function  affected: 
hallucinations,  delusions,  morbid  impulses,  etc. 

Mental  diseases  or  psychoses  are  affections  in  which 
mental  symptoms  constitute  a  prominent  feature.  They 
differ  from  such  mental  infirmities  as  idiocy,  constitutional 
psychopathic  states  and  some  states  of  dementia,  in  that  they 
are  expressions  of  active  pathological  processes  and  not  of 
permanent  and  fixed  alterations  of  the  mind. 

Psychic  infirmity,  when  not  congenital,  occurs  as  the 
outcome  of  mental  disease.  The  relation  between  the  two 
conditions  is  analogous  to  that  which  exists  between  anky- 
losis of  a  joint  and  the  arthritis  which  produced  it;  the  latter 
is  a  disease,  the  former  an  infirmity. 


Xiv  INTRODUCTION 

Two  general  terms  still  remain  to  be  defined:    men-' 
tal  alienation  and  insanity.     Although  they  are  often  em- 
ployed indiscriminately,  their  meaning  is  not  quite  identical. 

Etymologically,  an  alienated  (Lat.  alienus)  individual 
is  one  who  has  become  "  estranged  "  from  himself,  who 
has  loct  the  control  of  his  mental  activity,  who,  in  other 
words,  is  not  responsible  for  his  acts.  This  definition  rests 
upon  the  metaphysical  conception  of  a  free  wiU  and  cannot 
find  a  place  in  medical  science,  which  must  be  based  on 
observation  and  must  adhere  to  demonstrable  facts. 

It  is  better  to  adopt  an  essentially  practical  definition, 
as  has  been  done  by  most  modern  psychiatrists,  and  to 
designate  by  the  term  mental  alienation  the  entire  class  of 
pathological  states  in  which  the  mental  disorders,  whatever 
their  nature  be  otherwise,  present  an  anti-social  character. 
Not  every  individual  suffering  from  a  psychic  affection  is 
alienated.  This  term  can  be  appHed  only  to  those  who, 
on  account  of  some  mental  disease  or  infirmity,  are  Hkely 
to  enter  into  conflict  with  society  and  to  find  themselves,  in 
consequence,  unable  to  be  an  integral  part  of  it. 

Insanitij,  as  a  scientific  term,  has  fallen  into  disuse  and 
now  retains  significance  mainly  as  a  legal  one.  Like  lunacy, 
it  seems  destined  to  become  obsolete,  for  even  in  law  it  is  not 
used  without  stated  or  implied  further  specification,  such  as 
incompetence  necessitating  the  appointment  of  a  committee 
of  person  or  estate,  irresponsibility  in  a  criminal  action, 
limited  testamentary  capacity,  or  irrational  conduct  necessita- 
ting commitment  to  an  institution  for  treatment  and  cus- 
tody. Thus,  according  to  the  law  of  the  state  of  New  York, 
an  imbecile,  epileptic,  or  senile  dement  {"  dotard  ")  cannot  be 
committed  to  a  state  hospital  unless  he  is  at  the  same  time 
insane,  i.e.,  delusional,  depressed,  excited,  or  otherwise 
irrational  in  conduct;  similarly,  some  cases  of  hysteria, 
neurasthenia,  cerebral  arteriosclerosis,  or  brain  tumor  may 
be  declared  msane  and  committed  to  an  institution,  and 
others  not,  depending  on  their  manifestations  from  a  sociolo- 
logical  standpoint. 


INTRODUCTION  XV 

This  IManual  is  divided  into  three  parts.  The  first 
deals  with  general  psychiatry,  comprising  causes,  symptoms, 
methods  of  investigation,  treatment,  and  prevention  of 
mental  disorders  considered  independently  of  the  affections 
in  which  they  are  encounteped.  The  second  deals  with 
special  psychiatry,  that  is  to  say,  with  the  various  mental 
affections  individually.  The  third  consists  of  appendices 
giving  technique  of  special  diagnostic  procedures. 


MANUAL  OF  PSYCHIATRT 


PART   I 
GENERAL  PSYCHIATRY 


CHAPTER  I 
ETIOLOGY 

"  On  studying  closely  the  etiology  of  mental  diseases 
one  soon  recognizes  the  fact  that  in  the  great  majority  of 
cases  the  disease  is  produced — not  by  a  particular  or  specific 
cause,  but  by  a  series  of  unfavorable  conditions  which  first 
prepare  the  soil  and  then,  by  their  simultaneous  action,  deter- 
mine the  outbreak  of  insanity."  ^ 

This  was  written  nearly  three-quarters  of  a  century  ago. 
To-day,  though  this  view  is  still  held  to  a  certain  extent, 
we  are  nevertheless  able  to  distinguish  amongst  the  many 
causes  some  few  that  are  essential  from  others  that  are  merely 
incidental  or  contributing.  In  addition  there  are  other  factors 
that  have  to  do  with  the  etiology  of  mental  disorders, 
especially,  race,  age,  sex,  environment,  occupation,  marital 
condition,  education,  and  immigration. 

§  1.     Essential  Causes 

As  implied  in  the  term  itself,  the  essential  causes  are 
those  in  the  absence  of  which  mental  disorders  do  not  occur. 

1  Griesinger.     Die  Pathologie  und  Therapie  der  Geisteskrankheiten. 

1 


2  ETIOLOGY 

Of  these  by  far  the  most  important  are  heredity,  addiction 
to  alcohol  or  drugs,  syphilis,  and  head  injuries. 

Each  of  these  alone  may  suffice  to  produce  a  mental 
disorder  or  it  may  act  by  rendering  the  nervous  organi- 
zation so  vulnerable  that  a  breakdown  occurs  at  the  occa- 
sion of  some  incidental  cause  which  may  be  in  itself  quite 
insignificant  but  which  here  comes  to  play  the  part  of  "  the 
last  straw  that  broke  the  camel's  back." 

Heredity. — "  This  term  is  applied  to  the  fact  of  recurrence 
of  traits  in  a  number  of  blood  relatives,  due  to  their  posses- 
sion of  a  common  germ-plasm.  Hereditary  traits  are  those 
whose  development  depends  chiefly  upon  germinal  factors, 
genes,  or  determiners."^ 

Heredity  of  a  trait  is  direct,  when  the  trait  is  found  in 
parents  and  offspring;  atavistic,  when  one  or  more  genera- 
tions are  skipped;  collateral,  when  the  trait  is  found  pre- 
vailingly in  collateral  relatives  and  not  necessarily  in  the 
direct  line  of  ancestry. 

It  is  similar  when  the  condition  present  in  the  patient 
is  the  same  as  that  in  an  ascendant  or  collateral  relative; 
in  the  opposite  case  it  is  dissimilar.  The  latter  form  is  by  no 
means  uncommon:  among  the  ascendants  and  collateral 
relatives  of  psychotic  patients  are  to  be  found  instances  not 
only  of  similar  psychoses,  but  also  of  dissimilar  ones  and 
of  epilepsy,  feeble-mindedness,  criminality,  temperamental 
abnormalities,  sex  immorality,  and  other  neuropathic 
manifestations. 

The  fact  that  nervous  and  mental  diseases  are  often 
transmitted  by  heredity  was  known  to  Hippocrates  and 
has  since  his  time  been  amply  attested  by  psychiatric 
hospital  statistics,  but  the  exact  conditions  under  which  such 
transmission  occurs  have  never  been  fully  understood.  Espe- 
cially perplexing  has  been  the  seeming  irregularity  in  the 
working  of  heredity  as  presented,  on  the  one  hand,  in  the 
above-mentioned  facts  of  atavistic  and  collateral  heredity 

1  Definition  kindly  furnished  by  Dr.  C.  B.  Davenport,  in  a  personal 
communication. 


HEREDITY  3 

and,  on  the  other  hand,  in  the  frequent  failure  of  trans- 
mission of  neuropathic  traits.  Recent  investigations  have, 
however,  revealed  some  data  which  seem  to  indicate  that 
some  mental  disorders  are  transmitted  from  parent  to  off- 
spring in  the  manner  of  a  trait  which  is,  in  the  Mendelian 
sense,  recessive  to  the  normal  condition.^ 

The  bearing  of  the  Mendelian  theory  seems  to  be  of 
such  importance  in  this  connection  that  a  brief  state- 
ment of  it  may  not  be  considered  out  of  place. 

The  total  inheritance  of  an  individual  is  divisible  into  unit  char- 
acters each  of  which  is  inherited  more  or  less  independently  of  aU 
the  rest  and  may  therefore  be  studied  without  reference  to  other 
characters. 

The  inheritance  of  any  such  character  is  believed  to  be  dependent 
upon  the  presence  in  the  germ  plasm  of  a  unit  of  substance  caUed 
a  determiner. 

With  reference  to  any  given  character  the  condition  in  an  individual 
may  be  dominant  or  recessive:  the  character  is  dominant  when,  de- 
pending on  the  presence  of  its  determiner  in  the  germ  plasm,  it  is 
plainly  manifest;  and  it  is  recessive  when,  owing  to  the  lack  of  its 
determiner  in  the  germ  plasm,  it  is  not  present  in  the  individual  under 
consideration. 

The  dominant  and  recessive  conditions  of  a  character  are  often 
designated  by  the  symbols  D  and  R,  respectively. 

To  make  the  matter  clearer  we  may  take  as  an  example  of  a 
Mendelian  character  the  case  of  eye  color. 

The  brown  color  is  the  dominant  condition  while  the  blue  color 
is  the  recessive  condition,  as  has  been  shown  by  Davenport. ^  It 
would  seem  that  the  inheritance  of  brown  eyes  is  due  to  the  presence 
in  the  germ  plasm  of  a  determiner  upon  which  the  formation  of 
bro'RTi  pigment  is  the  anterior  layers  of  the  irides  depends. 

On  the  other  hand,  the  inheritance  of  blue  eyes  is  believed  to  be 
due  to  the  lack  of  the  determiner  for  brown  eye  pigment  in  the  germ 
plasm;  for  the  blue  color  of  eyes  is  due  merely  to  the  absence  of  brown 
pigment,  the  effect  of  blue  being  produced  by  the  choroid  coat  shining 

^  H.  H.  Goddard.  Heredity  of  Feeble-Mindedness.  Bulletin  No.  1, 
Eugenics  Record  Office,  Cold  Spring  Harbor,  N.  Y. — A.  J.  Rosanoff 
and  Florence  I.  Orr.  A  Study  of  Heredity  in  Insanity  in  the  Light 
of  the  Mendelian  Theory,  Bulletin  No.  5. — C.  B.  Davenport  and  D.  F. 
Weeks.     A  First  Study  of  Inheritance  in  Epilepsy.     Bulletin  No.  4. 

2  Science,  N.  S.,  Vol.  XXVI,  Nov.  1,  1907,  pp.  589-592.  . 


4  ETIOLOGY 

through  the  opalescent  but  pigment-free  anterior  layers  of  the  irides 
in  such  cases. 

It  must  be  borne  in  mind  that  as  regards  the  condition  of  any- 
character  every  person  inherits  from  two  sources,  namely,  from  each 
parent.  Therefore,  with  reference  to  any  character  he  may  be  pure 
bred  or  hybrid. 

A  case  of  inheritance  of  a  character  from  both  parents  is  spoken 
of  as  one  of  duplex  inheritance  and  is  often  designated  by  the  symbol 
DD. 

A  case  of  inheritance  of  a  character  from  only  one  parent  is  spoken 
of  as  one  of  simplex  inheritance  and  is  designated  by  the  symbol  DR. 

A  case  in  which  a  character  is  not  inherited  from  either  parent, 
therefore  exhibiting  the  recessive  condition,  is  spoken  of  as  one  of 
nulliplex  inheritance  and  is  designated  by  the  symbol  RR. 

We  are  now  in  a  position  to  estimate  the  relative  number  of  each 
type  of  offspring  according  to  thsoretical  expectation  in  the  various 
combinations  of  mates. 

There  are  but  six  theoretically  possible  combinations  of  mates. 
Continuing  to  make  use  of  the  case  of  eye  color  as  an  instance  of  a 
Mendelian  character,  let  us  consider  in  turn  each  theoretical  possi- 
bility. 

1.  Both  parents  blue-eyed  (nulliplex):  all  children  will  be  blue- 
eyed,  as  may  be  represented  by  the  following  biological  formula: 

RRXRR=RR. 

2.  One  parent  brown-eyed  and  simplex  (that  is  to  say,  inherit- 
ing the  determiner  for  brown  eye  pigment  from  one  grandparent 
only),  the  other  blue-eyed:  half  the  children  wiU  be  brown-eyed  and 
simplex  and  the  other  half  blue-eyed: 

DRXRR=DR+RR. 

3.  One  parent  brown-eyed  and  duplex,  the  other  blue-eyed:  all 
the  children  will  be  brown-eyed  and  simplex: 

DDXRR  =  DR. 

4.  Both  parents  brown-eyed  and  simplex:  one-fourth  of  the  chil- 
dren will  be  brown-eyed  and  duplex,  one-half  will  be  brown-eyed  and 
simplex,  and  the  remaining  one-fourth  will  be  blue-eyed  (nulliplex) : 

DRXDR  =  DD+2DR+RR. 

5.  Both  parents  brown-eyed,  one  duplex  the  other  simplex:  all 
the  children  will  be  brown-eyed,  half  duplex  and  half  simplex: 

DDXDR  =  DD+DR. 


HEREDITY  5 

6.  Both  parents  brown-eyed  and  duplex:  all  the  children  will 
be  brown-eyed  and  duplex: 

DDXDD  =  DD. 

It  will  be  readily  seen  from  these  formulse  that  in  attempting  to 
predict  the  proportions  of  the  various  types  of  offspring  that  may 
result  from  a  given  mating  it  is  necessary  to  know,  not  only  whether 
the  character  is  in  each  parent  dominant  or  recessive,  but  in  the  case 
of  the  dominant  condition  also  whether  it  is  duplex  or  simplex. 

Turning  again  to  the  case  of  eye  color,  an  individual  with  blue 
eyes  we  know  to  be  nuUiplex  as  he  has  no  brown  pigment  in  his  eyes 
and  therefore  could  not  have  inherited  the  determiner  for  brown 
eye  pigment  from  either  parent.  But  now  are  we  to  judge  in  the  case 
of  a  brown-eyed  person  whether  he  has  inherited  the  determiner  for 
that  character  from  both  parents  or  only  from  one?  We  can  judge 
this  only  by  a  study  of  the  ancestry  and  offspring  of  the  individual. 

To  put  the  whole  matter  in  a  nutshell,  the  essential  difference 
between  a  dominant  and  a  recessive  condition  of  a  character  is  in 
the  fact  that  in  a  case  of  simplex  inheritance  the  dominant  condi- 
tion is  plainly  manifest  while  the  recessive  condition  is  not  apparent 
and  can  be  known  to  exist  only  through  a  study  of  ancestry  and 
offspring. 

This  is  important  because  it  constitutes  the  criterion  by  which 
we  are  able  to  determine  whether  any  given  inherited  peculiarity 
or  abnormahty  is,  as  compared  with  the  average  or  normal  condition, 
dominant  or  recessive. 

According  to  the  assumption  that  most  of  the  inherit- 
able mental  disorders,  are,  like  the  trait  of  blue  eyes,  trans- 
mitted in  the  manner  of  Mendelian  recessives,  theoretical 
expectation  would  be  as  follows: 

1.  Both  parents  being  neuropathic,  all  children  will  be  neuro- 
pathic. 

2.  One  parent  being  normal  but  with  the  neuropathic  taint  from 
one  grandparent,  and  the  other  parent  being  neuropathic,  half  the 
children  will  be  neuropathic  and  half  will  be  normal,  but  capable  of 
transmitting  the  neuropathic  make-up  to  their  progeny. 

3.  One  parent  being  normal  and  of  pure  normal  ancestry,  and 
the  other  parent  being  neuropathic,  all  the  children  will  be  normal 
but  capable  of  transmitting  the  neuropathic  make-up  to  their  progeny. 

4.  Both  parents  being  normal,  but  each  with  the  neuropathic 
taint  from  one  grandparent,  one-fourth  of  the  children  will  be  normal 
and  not  capable  of  transmitting  the  neuropathic  make-up  to  their 


6 


ETIOLOGY 


progeny,  one-half  will  be  normal  but  capable  of  transmitting  the  neuro- 
pathic make-up,  and  the  remaining  one-fourth  will  be  neuropathic. 

5.  Both  parents  being  normal,  one  of  pure  normal  ancestry  and 
the  other  with  the  neuropathic  taint  from  one  grandparent,  all  the 
children  will  be  normal;  half  of  them  will  be  capable  and  half  not 
capable  of  transmitting  the  neuropathic  make-up  to  their  progeny. 

6.  Both  parents  being  normal  and  of  pure  normal  ancestry,  all 
the  children  will  be  normal  and  not  capable  of  transmitting  the  neuro- 
pathic make-up  to  their  progeny. 

Table  1  (from  Rosanoff  and  Orr,  loc.  cit.)  gives  actual 
findings  alongside  of  theoretical  expectation,  and  it  will 
be  seen  that  the  correspondence  between  the  two  sets  of 
figures  is  very  close. 

TABLE  1 


TjHpes  of  Mating. 


J2    bO 

a.s 

c3  O 


Neuro- 
pathic 
Off- 
spring. 


•  1"^  S 

,^    CO  I   g    "2 
3.3     (D   ra 


*   C 


Si  "■ 


Normal 

Off- 
spring. 


o  w 

Hf£] 


1.  RRXRR  =  RR 

2.  DRXRR  =  DR+RR 

3.  DDXRR  =  DR 

4.  DRXDR  =  DD+2DR+RR 

5.  DDXDR  =  DD+DR 

6.  DDXDD  =  DD 

Totals 


75 
500 

61 
369 

92 
0 


54    64 
190  214i 


10     0 
239!214i 


0 

107 

0 

0 


0 

80^ 

0 

0 


45 
215 

77 
0 


45 

241^ 

77 

0 


206 


1097 


146 


14 


351 


359 1  586 


578 


The  more  important  mental  disorders  which  are  sup- 
posed to  develop  on  a  hereditary  basis  are:  arrests  of  de- 
velopment, epileptic  psychoses,  constitutional  psychopathic 
states,  dementia  prsecox,  paranoia,  manic-depressive  psy- 
choses, involutional  melancholia,  psychoneuroses,  and  Hunt- 
ington's chorea.     Of  8700  cases  admitted  to  the  New  York 


ALCOHOLISM  7 

state  hospitals  during  the  year  ending  July  30,  1918,  5420, 
or  62.3%,  belonged  to  these  groups.^ 

Alcoholism. — The  most  trustworthy  experimental  data 
that  are  available,  among  which  may  be  mentioned  those 
of  Schneid  tr,^  Hellsten,^  Mayer,"*  Aschaffenburg,^  Smith,^ 
Klirz  and  Kraepelin,'^  seem  to  show  that  even  moderate 
indulgence  in  alcohol,  though  producing  in  the  subject  a  sense 
of  well-being  and  of  increased  physical  and  mental  ability, 
in  reality  causes  impairment  of  muscular  power  and  coordi- 
nation and  of  mental  efficiency. 

Excessive  indulgence  produces  the  sufficiently  familiar 
picture  of  drunkenness,  and  such  excesses,  if  frequently  re- 
peated, are  apt  sooner  or  later  to  produce  one  or  another 
of  the  alcoholic  psychoses,  of  which  the  more  important 
are:  delirium  tremens,  acute  hallucinogis,  a  fairly  char- 
acteristic chronic  delusional  state,  the  polyneuritic  psychosis, 
and  alcoholic  dementia.  During  the  year  ending  June  30, 
1918,  7.1%  of  all  male  admissions  and  2.6%  of  all  female 
admissions  to  the  New  York  state  hospitals  were  cases  of 
alcoholic  psychoses.^  This  does  not  include  cases  which 
were  not  specifically  alcoholic  but  in  which  intemperance 
was  given  as  a  contributing  cause. 

1  Thirtieth  Annual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1919. 

2  Pflueger's  Archiv.  f.  d.  gesamte  Physiologie,  Vol.  XCIII,  p.  451. 
2  Abstracted    in    Muenchener    medicinische    Wochenschrift,    1904, 

p.  1894. 

*  M.  Mayer.  Ueber  die  Beeinflussung  der  Schrift  durch  den  Alkohol. 
Kraepelin's  Psychol.  Arb.,  Vol.  Ill,  p.  535. 

^  G.  Aschaffenburg.  Praktische  Arbeit  unter  Alkoholvnrkung. 
Kraepehn's  Psychol.  Arb.,  Vol.  I,  p.  608. 

^  A.  Smith.  Ueber  die  Beeinflussung  einfacher  psychischer  Vor- 
gdnge  durch  chronische  Alkoholvergiftung.  Br.  ueber  d.  V.  intern. 
Kongr.  z.  Bekampf.  d.  Missbr.  geist.  Getranke,  Basel,  1896,  p.  341. 

^  Kiirz  and  Kraepelin.  Ueber  die  Beeinflussung  psychischer  Vor- 
gange  durch  regelmdssigen  Alkoholismus.  Kraepelin's  Psychol.  Arb., 
Vol.  Ill,  p.  417. 

^  Thirtieth  Annual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1919. 


8  ETIOLOGY 

Drug  Addictions. — In  March,  1918,  a  special  committee 
was  appointed  by  the  Secretary  of  the  Treasury  of  the  United 
States  to  investigate  the  traffic  in  narcotic  drugs.  This  com- 
mittee rendered  an  official  report  of  its  investigation  in  June, 
1919.  The  report  states  that  the  per  capita  consumption  of 
opium  in  the  United  States  amounts  to  36  grains  annually, 
the  consumption  in  some  other  countries  being  as  follows: 
Austria  |  to  f  grain;  Italy  1  grain;  Germany  2  grains; 
Portugal  2|  grains;  France  3  grains;  Holland  3|  grains. 
"  When  it  is  considered  that  the  greater  portion  of  our 
citizens  do  not  take  a  single  dose  of  opium  year  after  year, 
it  is  manifest  that  this  enormous  per  capita  consumption 
is  the  result  of  its  use  for  the  satisfaction  of  addiction." 

The  situation  as  regards  cocaine  is  somewhat  similar: 
"  112,500  ounces  of  cocaine,  which  is  manufactured  in  this 
country,  is  used  for  illicit  purposes,  and  this  does  not  include 
that  quantity  which  is  smuggled  into  this  country,  of  which 
no  estimate  can  be  made." 

"  The  committee  is  of  the  opinion  that  the  total  number 
of  addicts  in  this  country  probably  exceeds  1,000,000  at  the 
present  time." 

Hundreds  of  cases  came  to  light  in  drafted  men  between 
the  ages  of  21  and  31  in  the  National  Army  cantonments. 
The  drugs  used  in  100  consecutive  cases  observed  in  the 
Base  Hospital  at  Camp  Upton,  N.  Y.,  were  as  follows: 

TABLE  2 

Heroin 84  cases 

Morphine  and  heroin 5     " 

Morphine 4     " 

Opium  and  heroin 2     " 

Cocaine,  morphine  and  heroin 2     " 

Cocaine  and  heroin 1  case 

Morphine,  opium  and  heroin 1     " 

Opium  and  morphine 1     " 

Sjrphilis. — Syphilis  appears  as  the  essential  cause  of  all 
cases  of  general  paralysis  and  of  cerebral  syphilis  (gummata, 
meningitides,  etc.),  and  of  a  large  proportion  of  the  cases  of 


CONTRIBUTING  CAUSES  9 

cerebral  arteriosclerosis.  Not  counting  cases  of  the  latter 
condition,  which  are  not  always  of  syphilitic  origin,  21.2% 
of  all  male  first  admissions  and  6.5%  of  all  female  first 
admissions  to  the  New  York  state  hospitals  during  the  year 
ending  June  30,  1918,  occurred  on  the  basis  of  syphilis 
as  an  essential  cause. ^ 

Head  Injuries. — ^The  more  important  mental  disorders 
occurring  as  result  of  head  injuries  are:  traumatic  delirium, 
traumatic  constitution,  traumatic  epilepsy,  and  traumatic 
dementia.  These  cases  are  far  more  often  brought  to  general 
hospitals  than  to  hospitals  for  the  insane  for  reasons  that  are 
sufficiently  obvious.  Thus  only  0.3%  of  all  first  admissions 
to  the  New  York  state  hospitals  during  the  year  ending 
June  30,  1917,  were  cases  of  traumatic  psychoses.^ 

§  2.  Incidental  or  Contributing  Causes 

The  incidental  or  contributing  causes  are  remarkable  for 
their  multiplicity  and  complexity;  one  might  almost  say 
that  they  are  as  many  as  there  are  individual  cases  and  that 
in  no  two  cases  is  their  manner  of  action  exactly  alike.  In 
themselves,  however,  they  do  not  suffice  to  produce  a  mental 
disorder,  but  acquire  pathogenicity  only  in  the  presence  of  an 
essential  cause. 

Some  are  met  with  in  practice  with  special  frequency 
and  therefore  seem  to  possess  quasi-specific  potency  in  the 
production  of  mental  disorders. 

Alcoholism,  which  has  been  already  mentioned  as  an 
essential  cause,  may  also  act  as  a  contributing  cause  in  the 
presence  of  a  predisposition  created  by  one  of  the  other 
essential  causes.  Thus,  acting  on  a  basis  of  bad  heredity, 
alcoholism  may  determine  the  development  of  dementia 
prsecox  or  of  a  manic-depressive  or  an  epileptic  attack; 
and  some  hold  that  a  syphilitic  subject  who  is  also  intem- 

1  Thirtieth  Annual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1919. 


10  ETIOLOGY 

perate  is  moi-e  likely  to  develop  general  paralysis  than  one 
who  is  abstinent.  Thus,  of  the  16.2%  of  first  admissions  to 
the  New  York  state  hospitals  during  the  year  ending  June 
30,  1918,  in  which  there  was  a  record  of  intemperance,  only 
5.2%  were  cases  of  specifically  alcoholic  psychoses,  the 
remaining  11.0%  being  cases  in  which  alcoholism  played 
the  part  merely  of  a  contributing  cause.^ 

Head  injuries,  like  alcoholism,  are  probably  capable 
of  acting  not  only  as  essential  but  also  as  contributing 
causes,  especially  as  factors  in  the  etiology  of  general  paral- 
ysis; their  importance  in  this  connection  will  be  again 
discussed  in  the  chapter  devoted  to  this  disease. 

For  the  rest,  recent  studies  seem  to  indicate  that  the 
incidental  or  contributing  causes  that  are  met  with  are 
psychic  rather  than  physical  in  their  nature  or  manner  of 
operation  .2 

Even  such  causes  as  pregnancy,  abortion,  rhildbirth,  and 
lactation  are  found  in  the  better  analyzed  cases  to  act  not  as 
physical  causes,  but  through  psychic  accompaniments,  such 
as  illegitimacy,  increasingly  hopeless  domestic  infelicity, 
apprehension  of  added  hardships;  although  it  is  undoubtedly 
also  true  that  such  conditions  as  febrile  or  exhaustion  deliria 
may  be  produced  by  these  causes  acting  in  a  physical  way, 
especially  in  the  presence  of  complications  like  excessive 
hemorrhage  or  infection. 

Among  the  plainly  psychic  causes  may  be  mentioned  the 
following  as  being  the  more  common:  Business  troubles: 
financial  difficulties,  loss  of  employment,  inability  to  get 
employment,    failure    in    school    examinations.     Domestic 

1  Thirtieth  Annual  Report  of  the  N.  Y.  State  Hospital  Commission 
Albany,  1919. 

2  Adolf  Meyer.  The  Role  of  the  Mental  Factors  in  Psychiatry. 
N.  Y.  State  Hosp.  Bulletin,  N.  S.,  Vol.  I,  1908,  p.  262.— Jung.  The 
Psychology  of  Dementia  PrcECox.  English  translation  by  Peterson  and 
Brill,  New  York,  1909. — A.  J.  Rosanoff.  Exciting  Causes  in  Psychiatry. 
Amer.  Joum.  of  Insanity,  Vol.  LXIX,  1912,  p.  351. — August  Hoch. 
Precipitating  Mental  Causes  in  Dementia  Proecox.  Amer.  Journ.  of 
Insanity,  Vol.  LXX,  1914,  p.  637. 


CONTRIBUTING  CAUSES  11 

troubles:  abuse  by  husband,  infidelity  of  husband,  intem- 
perance of  husband,  desertion,  other  conditions  of  marital 
infelicity.  Love  affairs:  disappointment  in  love,  unre- 
quited love.     Death  or  illness  of  relatives. 

The  relative  parts  played  by  the  essential  and  incidental 
or  contributing  causes  are  not  the  same  in  all  cases. 

In  such  conditions  as  arrests  of  development,  epilepsy, 
marked  constitutional  psychopathic  states,  and  Huntington's 
chorea  bad  heredity  alone  suffices  to  produce  the  infirmity 
and  to  render  it  manifest. 

In  the  constitutional  psychoses,  too,  the  factor  of  bad 
heredity  seems  often  to  be  the  all  important  one.  "  In  more 
than  half  of  the  cases  indications  for  commitment  have  arisen 
in  the  midst  of  an  average  environment  and  in  the  absence 
of  occasion  of  special  difficulty  or  strain."  ^  "  On  the  whole 
exogenous  factors  appear  to  be  of  but  minor  importance: 
the  amount  of  psychotic  manifestation  is,  for  the  most  part, 
like  its  kind,  predetermined  in  the  germ  plasm."  ^  It  is  a 
remarkable  fact,  significant  in  this  connection,  that  the 
World  War  produced  no  increase  in  the  insanity  rate,  as 
judged  by  numbers  of  cases  admitted  to  institutions.^ 

In  the  psychoneuroses  environmental  factors  often  deter- 
mine the  manifestations;  i.e.,  while  here,  too,  the  disorder 
cannot  arise  in  the  absence  of  the  constitutional  factor, 
that  factor  alone,  in  a  large  proportion  of  the  cases,  produces 
no  manifestations,  but  remains  latent  until  some  external 
cause  brings  it  to  light.     This  accounts  for  the  vast  numbers 

1  A.  J.  Rosanoff.  Exciting  Causes  in  Psychiatry.  Amer.  Journ.  of 
Insanity,  Oct.,  1912. 

2  A.  J.  Rosanoff.  Dissimilar  Heredity  in  Mental  Disease.  Amer. 
Joum.  of  Insanity,  July,  1913. 

3  Board  of  Control,  Great  Britain.  Insanity  and  the  War.  Third 
Annual  Report,  1916. — R.  H.  Steen.  Fifty-first  Annual  Report. 
London  Asylum  and  Hospital  for  Mental  Diseases,  1916. — K.  Birn- 
baum.  Kriegsneurosen  und  --psy chosen  auf  Grund  der  gegenwdrtigen 
Kriegsbeobachtungen;  erste  Zusamynenstellung  vom  Kriegsbeginn  bis 
Mitte  Mdrz,  1915.  Zeitschr.  f.  d.  gesamte  Neurologie  u.  Psychiatrie, 
1915. 


12 


ETIOLOGY 


of  psychoneuroses  observed  in  all  armies  during  the  World 
War. 

§  3.     Other  Etiological  Factors 

Race. — An  excellent  opportunity  of  investigating  the 
influence  of  race  on  the  occurrence  of  mental  disorders  is 
afforded  by  the  experience  of  the  hospitals  for  the  insane 
serving  the  city  of  New  York,  where  people  of  various  races 
are  living  under  approximately  similar  conditions.  This 
opportunity  has  been  well  utiHzed  in  a  study  by  Kirby.^ 
Table  3,  compiled  from  the  figures  furnished  in  that  study, 
shows  the  relative  frequency  of  certain  psychoses  in  people 
of  different  races,  given  in  figures  representing  percentages 
of  the  total  number  of  admissions  for  each  race  to  the  Man- 
hattan State  Hospital,  on  Ward's  Island,  during  the  year 
ending  September  30,  1908.  It  will  be  observed  that  the 
Irish  are  most  liable  to  alcoholic  psychoses,  while  the  Jews 
are  practically  free  from  them;  the  latter,  on  the  other 
hand,  suffer  most  from  the  constitutional  psychoses,  especially 
dementia  precox  and  manic-depressive  psychoses.  The 
negroes  are  most  liable  to  general  paralysis. 

TABLE  3 


Psychoses. 


O 


Senile  psychoses 

General  paralysis 

Alcoholic  psychoses 

Dementia  prsecox 

Manic-depressive  psychoses 

Epileptic  psychoses 

Other  psychoses 

Total  number  of  each  race. . 


% 

9.80 

7.59 
27.69 
13.48 
16.66 

2.20 
22.58 


% 

2.87 
14.05 

0.32 
27.47 
28.43 

1.59 
25.27 


% 

6.70 
20.10 
11.85 
14.95 
12.89 

4.64 
28.87 


% 

7.14 
17.46 
11.90 
16.66 
18.25 

3.17 
25.42 


% 

3.70 

9.87 

8.64 

23.44 

13.58 

4.93 

35.84 


% 

9.80 
29.41 

7.82 
13.72 

9.80 

3.92 
25.53 


408 


313 


194 


126 


81 


51 


1  Geo.  H.  Kirby.    A  Study  in  Race  Psijchopathology. 
Hosp.  Bulletin,  N.  S.,  Vol.  I,  1909,  p.  663. 


N.  Y.  State 


AGE 


13 


General  paralysis  is  said  to  be  rare  in  Arabs  and  African 
negroes,  although  syphihs  is  common.  This,  however,  is 
hardly  more  than  a  mere  impression,  satisfactory  statistical 
data  pertaining  to  this  subject  being  as  yet  not  available. 

Age. — All  ages  do  not  equally  predispose  to  mental 
disorders.  In  general  it  appears  that  the  incidence  of  the 
psychoses,  as  indicated  by  state  hospital  admissions,  increases 
sharply  with  advancing  age.  This  is  shown  in  Table  4, 
which  is  based  on  statistics  of  population  given  in  the 
Thirteenth  Census  of  the  United  States  and  on  those  of  hos- 
pital admissions  furnished  by  the  New  York  State  Hospital 
Commission.^ 


TABLE  4 


Age  Groups. 


Population, 
1910. 


First  Ad- 
missions to 
the  State 
Hospitals. 


Admissions 
per  100,000 
of  Popu- 
lation. 


Under  15  years . 

15  to  19 

20  to  24 

25  to  29 

30  to  34 

35  to  39 

40  to  44 

45  to  49 

50  to  54 

65  to  59 

60  to  64 

65  years  and  over. 

All  ages  * 


2,459,923 
831,884 
920,433 
857,801 
750,725 
696,837 
589,428 
495,849 
412,759 
290,795 
235,307 
414,336 

8,966,842 


14 
282 
607 
675 
647 
625 
599 
497 
444 
322 
251 
666 
5660 


0.6 

33.9 

65.9 

78.7 

86.2 

89.7 

101.6 

100.2 

107.6 

110.7 

106.7 

160.7 

63.1 


*  Including  those  of  unknown  age. 

The  ages  of  greatest  susceptibility  are  not  the  same 
for  all  psychoses.  Senile  dementia  seldom  if  ever  occurs 
before  the  age  of  60.  Similarly,  involutional  melancholia 
is  rarely  seen  before  the  age  of  40.     More  than  half  of  all 

1  Twenty-third  Annual  Report,  Albany,  N.  Y.,  1912. 


14  ETIOLOGY 

cases  of  general  paralysis  are  seen  between  the  ages  of  35  and 
50.  The  onset  of  more  than  half  of  all  cases  of  dementia 
praicox  and  manic-depressive  psychoses  is  before  the  age  of 
30.  More  detailed  considerations  of  age  are  given  in  the 
chapters  devoted  to  the  various  psychoses. 

Sex. — Mental  disorders  are  more  frequent  in  the  male 
than  in  the  female  sex.  Thus  an  enumeration  of  patients 
in  institutions  for  the  insane  made  on  January  1,  1910, 
showed  for  the  entire  United  States  an  average  of  208.5 
men  and  only  199.6  women  per  100,000  of  the  general  popu- 
lation. An  even  greater  contrast  was  presented  by  the  ad- 
missions to  the  institutions  during  the  year  1910,  which  were 
72.1  men  and  59.7  women  per  100,000  of  the  general  popula- 
tion. This  difference  seems  to  be  due  entirely  to  the  greater 
frequency  of  general  paralysis  and  of  alcoholic  psychoses 
among  men,  the  admissions  for  all  psychoses  other  than 
these  being  about  the  same  for  the  two  sexes,  averaging 
54.4  men  and  55.6  women  per  100,000  of  the  general  popula- 
tion. ^ 

Environment. — Statistics  show  almost  invariably  that 
urban  populations  contribute  relatively  much  greater  num- 
bers of  admissions  to  institutions  for  the  insane  than  do 
rural  ones.  Thus  during  the  year  1910  the  urban  popula- 
tion 2  of  the  United  States  contributed  102.8  admissions, 
and  the  rural  population  but  41.4  per  100,000.^  This  differ- 
ence can  be  partly  accounted  for  by  the  greater  prevalence 
of  alcoholism  and  syphilis  in  urban  populations.  Another 
factor  having  a  bearing  here  is  the  difference  between  the 
two  portions  of  the  population  in  age  distribution:  only 
27.2%  of  the  urban  population  and  as  many  as  36.3%  of 
the  rural  population  were  under  15  years  of  age;  we  have 

^Insane  and  Feeble-Minded  in  Institutions.  Bureau  of  the  Census, 
Washington,  1914. 

2 The  expression  "urban  population"  is  here  used,  as  in  the  U.  S. 
Census,  to  designate  all  that  part  of  the  population  which  resides  in 
cities,  towns,  or  'other  incorporated  places  of  2500  inhabitants  or 
more. 


OCCUPATION— MARITAL  CONDITION  15 

already  shown  that  the  population  groups  under  15  years 
of  age  contribute  but  a  very  minute  proportion  of  admissions 
to  institutions  for  the  insane. 

For  the  rest,  it  seems  probable  that  the  difference  be- 
tween urban  and  rural  populations,  as  shown  in  statistics, 
is  due  not  to  a  corresponding  difference  in  incidence  of  mental 
disorders,  but  to  purely  extraneous  conditions,  especially 
accessibility  of  institutions.^ 

Occupation. — It  is  hardly  to  be  doubted  that  occupation 
has  an  influence  on  the  incidence  of  mental  disorders,  al- 
though satisfactory  statistics  pertaining  to  this  matter  are 
not  available.  Bartenders,  brewery  and  distillery  em- 
ployees, and  hotel  waiters  are  more  liable  than  most  others 
to  alcoholic  psychoses;  soldiers,  sailors,  traveling  salesmen 
and  railroad  employees  are  more  liable  to  general  paralysis. 
Physicians,  engineers,  architects,  clergymen,  and  lawyers 
would  probably  show  a  relatively  low  incidence  of  the 
graver  constitutional  psychoses. 

Marital  Condition. — Of  all  patients  admitted  to  the 
institutions  for  the  insane  in  the  United  States  during  the 
year  1910,  48.4%  among  men  and  33.4%  among  women 
were  single.  In  the  adult  population  at  large  only  38.7% 
of  the  men  and  29.7%  of  the  women  were  single — this  in 
spite  of  the  fact  that  the  average  age  of  patients  admitted 
is  higher  than  that  of  the  general  adult  population  (over  15 
years  of  age)  and  that,  on  that  score,  the  percentage  of 
single  persons  should  be  less  and  not  greater  among  the 
hospital  admissions.  This,  however,  "  is  not  to  be  inter- 
preted as  indicating  that  the  single  are  more  liable  to  become 
insane  than  the  married.  It  means  rather  that  the  insane 
as  compared  with  the  normal  are  less  likely  to  marry."  ^ 

An  interesting  relationship  is  also  to  be  observed  between 
certain  psychoses  and  the  state  of  widowhood,  divorces  and 

^  A.  J.  Rosanoff.  A  Study  of  Eugenic  Forces.  Amer.  Journ.  of 
Insanity,  Vol.  LXXII,  1915. 

2  Insane  and  Feeble-Minded  in  Institutions.  Bureau  of  the  Census, 
Washington,  1914. 


16 


ETIOLOGY 


separations.  Table  5,  copied  from  statistics  furnished  by* 
the  New  York  State  Hospital  Commission/  shows  that  the 
percentages  of  the  widowed,  divorced,  and  separated  were 
highest  in  the  general  paralysis  and  alcoholic  groups;  the 
table  also  shows  that  the  groups  of  constitutional  psychoses 
have  the  highest  percentages  of  single  persons. 

TABLE  5 


Psychoses. 


Per  cent  of  Total  of  Each  Psychosis. 


Single. 


Males. 


Fem. 


Widowed. 


Males. 


Fem. 


Divorced 

and 
Separated. 


Males. 


Fem. 


General  paralysis 

Alcoholic  psychoses .  . . 

Dementia  praecox 

Manic-depr.  psychoses 


26.0 
39.5 
81.4 
60.1 


14.8 
11.9 
58.0 
41.3 


5.5 
9.8 
2.0 

4.5 


21.3 

23.1 

6.6 

9.2 


6.7 
6.6 
2.2 
2.1 


5.5 
9.7 
3.3 
3.1 


Education. — That  the  factor  of  education  is  in  some  man- 
ner related  to  the  incidence  of  mental  disorders  is  uniformly 
indicated  by  statistics  representing  the  experience  of  every 
state  in  the  country.  Thus  on  January,  1,  1910,  there 
were  881.8  persons  in  institutions  for  the  insane  per  100,000 
of  the  white  illiterate  population  10  years  of  age  or  over  in 
the  United  States  and  only  225.8  per  100,000  of  the  Hterate 
population.  The  constitutional  psychoses,  far  more  than 
others,*"  contribute  to  this  showing. 

The  conclusion  could  hardly  be  drawn  from  this  that 
illiteracy  is  to  any  great  extent  a  cause  of  mental  disease, 
rather  the  reverse  being  true  for  the  most  part:  the  clinical 
histories  of  the  illiterate  insane  show  that  most  of  them 
had  been  unable  to  learn  to  read  and  write  owing  to  inherent 
mental  defectiveness. 


Twenty-fifth  Annual  Report,  Albany,  N.  Y.,  1914. 


IMMIGRATION  17 

Immigration. — Immigration  in  relation  to  insanity  pre- 
sents in  this  country  a  problem  of  great  magnitude.  Of  all 
the  insane  in  institutions  in  the  United  States  according  to 
the  enumeration  of  the  Thirteenth  Census  29.3%  were  foreign 
born;  of  the  native  insane  30.7%  were  of  foreign  or  mixed 
parentage.  The  figures  given  for  the  state  of  New  York 
are  even  more  strildng:  41.4%  were  foreign  born;  of  the 
native  insane  51.0%  were  of  foreign  or  mixed  parentage. 

Furthermore  it  has  been  shown  that  during  the  year 
ending  September  30,  1911,  the  native  population  of  the 
state  of  New  York  furnished  46.4  first  admissions  per 
100,000  to  the  state  hospitals,  while  the  foreign  born  popula- 
tion furnished  100.3 — relatively  2.19  times  as  many.^ 

This  raises  the  important  question  whether  the  in- 
cidence of  insanity  is  really  greater  among  the  immigrant 
races  than  in  the  older  white  population  in  this  country  or 
whether  some  other  conditions  are  responsible  for  this 
shovi^ing. 

A  study  of  the  available  statistics  has  shown  that  the 
difference  in  age  distribution  which  exists  between  the  native 
and  foreign-born  parts  of  the  population  accounts  largely, 
but  not  wholly,  for  the  difference  in  the  proportion  of  insane 
hospital  admissions. 

The  difference  is  further,  but  still  not  wholly,  accounted 
for  by  the  greater  proportion  of  town  dwellers  among  the 
foreign-born  than  among  the  native  population. 

Upon  eliminating  the  errors  resulting  from  these  dis- 
turbing factors  there  remains  but  a  slight  difference  between 
the  native  and  foreign-born  parts  of  the  population  in  the 
incidence  of  certified  insanity. 

It  is  thought  that  this  remaining  slight  difference  may  be 
accounted  for  by  the  heavy  stress  entailed  in  the  migration 
and  in  the  subsequent  process  of  adjustment  to  new  conditions 
and  more  exacting  standards  of  living,  and,  possibly,  by  other, 
less  obvious,  disturbing  factors. 

^  H.  M.  Pollock.  A  Statistical  Study  of  the  Foreign-Born  Insane 
in  the  N.  Y.  State  Hospitals.     N.  Y.  State  Hosp.  Bulletin,  April,  1912. 


18  ETIOLOGY 

Incidentally,  it  was  shown  that  the  migration  of  native 
American  masses  of  population  from  the  eastern  to  the 
western  coast  has  produced  a  similar  effect  in  creating  a 
seeming  increase  in  the  incidence  of  certified  insanity; 
natives  of  the  state  of  New  York  who  have  emigrated  to 
California  have  contributed  proportionately  2.60  times  as 
many  admissions  to  the  state  hospitals  there  as  the  native 
Californians,  a  showing  even  more  unfavorable  than  that 
made  by  the  foreign-born  population  in  the  state  of  New 
York. 

Owing  to  the  practical  impossibility  of  eliminating 
all  sources  of  error  in  a  direct  comparison  of  the  insanity 
rates  in  the  native  and  foreign-born  parts  of  the  population, 
an  attempt  was  made  to  make  the  comparison  by  an  indirect 
method. 

Insanity  being  in  large  measure  transmissible  by  hered- 
ity, any  real  difference  in  its  incidence  which  may  exist 
between  the  native  and  foreign-born  parts  of  the  population 
should  be  as  patent  in  the  offspring  as  in  the  parents;  in 
other  words,  it  should  be  as  evident  between  native  persons 
of  native  parentage  and  native  persons  of  foreign  parentage 
as  it  is  between  the  native  and  foreign-born  themselves. 

Calculation  shows  that  in  the  state  of  New  York  in  the 
fiscal  year  ending  September  30,  1911,  the  native  of  native 
parentage  contributed  34.6  first  admissions  to  the  state 
hospitals  per  100,000  of  their  general  population,  while  the 
native  of  foreign  parentage  contributed  34.9 — practically 
the  same  proportion. ^ 

The  conclusion  may,  therefore,  be  drawn  that  there  is 
no  evidence  to  show  that  there  is  a  greater  proneness  toward 
mental  disease  in  the  foreign-born  than  in  the  native  popu- 
lation and  that  the  excessive  proportion  of  hospital  admissions 
furnished  by  the  foreign-born  is  due  to  other  causes. 

1  A.  J.  Rosanoff.  Some  Neglected  Phases  of  Immigration  in  Relation 
to  Insanity.     Amer.  Journ.  of  Insanity,  Vol.  LXXII,  1915. 


CHAPTER  II 

SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

INSUFFICIENCY  OF  PERCEPTION— ILLUSIONS- 
HALLUCINATIONS 

"  The  senses,"  says  Johannes  Mueller,  "  inform  us  of  the 
various  conditions  of  our  body  by  the  special  sensations 
transmitted  through  the  sensory  nerves.  They  also  enable 
us  to  recognize  the  qualities  and  the  changes  of  the  bodies 
which  surround  us,  in  so  far  as  these  determine  the  particu- 
lar state  of  the  nerves."  ^  The  senses,  in  other  words,  are 
the  means  through  which  we  obtain  the  knowledge  of  our 
own  bodies  and  of  the  external  world. 

For  the  exercise  of  their  function  are  necessary:  (1)  the 
reception  of  an  internal  or  an  external  impression  by  a 
peripheral  organ;  (2)  the  transmission  of  this  impression 
to  the  brain;  (3)  its  elaboration  in  the  brain,  which  trans- 
forms it  into  a  phenomenon  of  consciousness :  first  sensation, 
then  perception.  Only  the  latter  operation  is  of  interest 
to  the  psychiatrist. 

We  shall  study  successively: 

I.  Insufficiency  of  perception; 

II.  Illusions  (inaccurate  perceptions); 

III.  Hallucinations  (imaginary  perceptions).  Halluci- 
nations and  illusions  are  often  classed  together  under  the 
name  of  psychosensory  disorders. 

§  1.    Insufficiency  of  Perception 

Insufficiency  of  perception  in  its  slightest  degree  may 
be  met  with  in  states  of  depression,  at  the  onset  of  con- 
1  Johannes  Mueller.     Handbuch  der  Physiologie. 
19 


20       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

fusional  states,  etc.  All  external  impressions  are  vague, 
uncertain,  and  strange.  The  patients  complain  that  every- 
thing has  changed  in  them  and  around  them:  objects  and 
persons  have  no  more  their  usual  aspect;  the  sound  of  their 
own  voice  startles  them. 

In  a  more  marked  degree  of  insufficiency  external  im- 
pressions no  longer  convey  to  the  mind  of  the  subject  any 
clear  or  precise  idea;  questions  are  either  not  understood 
at  all,  or  understood  only  when  they  are  very  simple,  brief, 
energetically  put,  and  repeated  several  times.  External 
stimulation,  even  the  strongest,  is  but  vaguely  perceived 
and  often  causes  no  reaction  proportionate  to  its  intensity 
or  appropriate  to  its  nature. 

Finally,  complete  paralysis  of  one  or  several  forms  of 
psychosensory  activity  is  observed  in  connection  with 
profound  disorders  of  consciousness,  as  in  mental  confusion 
of  the  stuporous  form. 

Insufficiency  of  perception  constitutes  an  important 
element  of  clouding  of  consciousness,  which  will  be  con- 
sidered later  on. 

Its  pathogenesis  is  closely  connected  with  disorders  of 
ideation.  The  normal  act  of  perception  really  consists  of 
two  elements:  (1)  a  sensory  impression;  (2)  a  series  of 
associations  of  ideas  which  enables  the  mind  to  recognize 
the  impression  and  which  almost  always  completes  it  and 
renders  it  more  definite.  If  the  associations  of  ideas  are  not 
formed  in  sufficient  numbers  the  perception  can  only  be  vague 
and  Ul  defined. 

§  2.    Illusions  (Inaccurate  Perceptions) 

An  illusion  may  be  defined  as  a  perception  which  alters 
the  quahties  of  the  object  perceived  and  presents  it  to  con- 
sciousness in  a  form  other  than  its  real  one.  One  who  hears 
insulting  words  in  the  singing  of  birds  or  in  the  noise  of  car- 
riage-wheels experiences  an  illusion. 

Illusions  are  of  frequent  occurrence  in  normal  persons. 


ILLUSIONS— HALLUCINATIONS  21 

There  is  no  one  to  whom  the  folds  of  a  curtain  seen  in  the 
dark  have  not  appeared  to  assume  more  or  less  fantastic 
shapes.  But  the  mind,  aided  by  the  testimony  of  the  other 
senses,  recognizes  the  abnormal  character  of  the  image; 
the  illusion  is  recognized  as  such.  In  psychotic  cases  it  is 
on  the  contrary  taken  for  an  exact  perception  and  exercises 
a  more  or  less  marked  influence  upon  all  the  psychic 
functions. 

Illusions  may  affect  any  of  the  senses  and  present,  in  the 
case  of  each,  features  analogous  to  those  of  hallucinations; 
we  shall  therefore  not  describe  them  here.  We  shall  say  but 
a  few  words  concerning  illusions  of  sight  which  present 
certain  peculiarities. 

Illusions  of  sight  may  occur  in  most  of  the  psychoses, 
but  are  chiefly  found  in  the  toxic  psychoses  and  in  the 
infectious  deliria.  When  these  illusions  pertain  to  persons 
they  lead  to  mistakes  of  identity.  Many  psychotics  mistake 
feUow  patients  or  employees  of  the  institution  for  relatives 
or  friends.  This  form  of  illusion  sometimes  attains  such 
completeness  that  the  subject  may,  while  at  a  hospital, 
beUeve  himself  to  be  at  his  home. 

Illusions  are  very  apt  to  occur  in  the  midst  of  vague 
impressions:  those  of  hearing  in  the  presence  of  confusing 
noises,  and  those  of  sight  in  partial  darkness. 

Like  incomplete  perceptions,  inaccurate  perceptions 
or  illusions  are  the  consequence  of  a  disorder  of  ideation; 
abnormal  associations  replace  normal  ones,  which  are  absent, 
and  complete  the  image,  altering  it  at  the  same  time. 


§  3.     Hallucinations  (Imaginary  Perceptions) 

"  A  person  who  has  an  inmost  conviction  of  a  sensation 
actually  perceived,  when  no  external  object  capable  of  ex- 
citing such  sensation  is  within  reach  of  the  senses,  is  in  a 
state  of  hallucination  "  (Esquirol). 

"  By  hallucinations  are  understood  subjective  sensory 


22       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

images  which  are  projected  outwardly  and  which  in  that 
way  acquire  objectivity  and  reality  "  (Griesinger) . 

"  A  hallucination  is  a  perception  without  an  object " 
(Ball). 

These  three  definitions  are  essentially  identical.  That 
of  Ball  appears  to  us  to  be  the  best  on  account  of  its  con- 
ciseness. 

Hallucinations  may  affect  any  of  the  senses.  There 
are  therefore  as  many  varieties  of  hallucinations  as  there  are 
senses. 

Some  properties  are  common  to  all  varieties  of  halluci- 
nations, others  are  peculiar  to  certain  varieties. 

A.    PROPERTIES    COMMON    TO    ALL    VARIETIES    OF 
HALLUCINATIONS 

Hallucinations  exercise  an  influence  upon  the  general 
psychic  condition  of  the  patient,  which  varies  with  the 
subject,  the  nature  of  the  disease,  and  the  different  stages 
of  the  same  disease. 

In  a  general  way  it  may  be  stated  that  the  more  acute 
the  character  of  the  mental  disorder  (acute  psychoses, 
periods  of  exacerbation  in  chronic  psychoses)  and  the  less 
enfeebled  the  intellectual  activity,  the  more  marked  is  the 
influence  of  the  hallucinations.  In  accordance  with  this 
rule,  the  correctness  of  which  is  clinically  demonstrated, 
hallucinations  abate  in  their  influence  as  the  acute  stage  of 
the  psychosis  subsides — either  when  the  patient  enters 
upon  convalescence,  or  when  he  lapses  into  dementia;  under 
such  conditions  they  may  persist  for  a  greater  or  lesser 
length  of  time  without  exercising  any  influence  upon  the 
patient's  emotions  or  actions. 

Influence  of  Hallucinations  upon  the  Psychic  Functions. — 
Attention. — Hallucinations  force  themselves  upon  the  at- 
tention of  the  patient.  In  the  case  of  hallucinations  of 
hearing,  for  instance,  he  is  compelled  to  listen  to  them, 
sometimes  in  spite  of  himself,  no  matter  what  their  degree 


HALLUCINATIONS  23 

of  clearness  is — whether  they  consist  of  distinctly  spoken 
words  or  phrases,  or  of  a  scarcely  perceptible  murmur. 

The  patient  is  sometimes  conscious  of  the  tyrannical 
dominating  power  to  which  he  is  subjected.  "  I  am  forced 
to  listen  to  them,"  said  one  of  these  unfortunates;  "  when 
they  (his  persecutors)  get  at  me  I  can  do  no  work,  cannot 
follow  any  conversation,  I  am  wholly  in  their  power.''  Hallu- 
cinations thus  resemble  imperative  ideas  and  autochthonous 
ideas  which  we  shall  study  later  on. 

Judgment. — Hallucinations  may  coexist  with  sound 
judgment  and  be  recognized  by  the  patient  as  a  patho- 
logical phenomenon.  They  are  then  called  conscious  hal- 
lucinations. Such  instances  are  not  very  rare  and  consist 
chiefly  of  hallucinations  of  sight.  A  celebrated  case  is  that 
of  Nicolai,  the  bookseller.  "  The  visions  began  in  1791, 
after  an  omission  of  a  bloodletting  and  an  application  of 
leeches  which  he  underwent  habitually  for  hemorrhoids. 
All  of  a  sudden,  following  a  strong  emotion,  he  saw  before  him 
the  form  of  a  dead  person,  and  on  the  same  day  diverse  other 
figures  passed  before  his  eyes.  This  repeated  itself  on 
numerous  occasions. 

"  The  visions  were  involuntary  and  he  was  unable  to 
form  an  image  of  any  person  at  will.  Most  of  the  time, 
also,  the  phantoms  were  those  of  persons  unknown  to  him. 
They  appeared  during  the  day  as  well  as  during  the  night, 
assuming  the  colors  of  the  natural  objects,  though  they  were 
somewhat  paler.  After  a  few  days  they  began  also  to  speak. 
One  month  after  the  onset  of  this  affection,  leeches  were 
applied;  on  the  same  day  the  figures  became  more  hazy 
and  less  mobile.  They  disappeared  finally  after  Nicolai 
had  for  some  time  seen  only  certain  portions  of  some  of 
them."  1 

Some  individuals  possess  the  power  of  producing  hal- 
lucinations at  will.  Goethe  had  that  power.  "  As  I  shut 
my  eyes,"  he  said,  "  and  lower  my  head  I  figure  to  myself 
a  flower  in  the  center  of  my  visual  organ;  this  flower  does 
1  Johannes  Mueller,     Loc.  cit. 


24       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

not  retain  for  an  instant  its  original  form;  it  forthwith 
rearranges  itself  and  from  its  interior  appear  other  flowers 
with  multicolored  or  sometimes  green  petals;  they  are  not 
natural  flowers,  but  fantastic,  though  regular,  figures  like 
the  rosettes  of  the  sculptors.  It  is  impossible  for  me  to  fix 
the  creation,  but  it  lasts  as  long  as  I  desire  without  increasing 
or  diminishing.''  ^ 

In  the  great  majority  of  cases  the  judgment,  itself  dis- 
ordered, is  unable  to  correct  the  psychosensory  error: 
the  hallucination  is  taken  for  a  true  perception.  Though 
sometimes  in  the  beginning  of  the  disease  the  subject  ex- 
periences some  doubts,  this  transitory  incertitude  is  soon 
replaced  by  a  blind  belief  in  the  imaginary  perception. 
"  We  observe,"  says  Wernicke,  "  that  the  reality  of  a  halluci- 
nation is  maintained  against  the  testimony  of  all  the  other 
senses,  and  that  the  patient  resorts  to  the  most  fantastic 
explanations,  rather  than  admit  any  doubt  as  to  the  reality 
of  his  perception."  ^  An  individual,  alone  in  the  open 
field,  hears  a  voice  calling  him  a  thief.  He  will  invent  the 
most  absurd  hypotheses  rather  than  believe  himself  a 
victim  of  a  pathological  disorder. 

Certain  patients,  chiefly  the  feeble-minded  and  the 
demented,  accept  their  hallucinations  without  inquiring 
as  to  their  origin  or  mechanism;  others  on  the  contrary 
strive  to  give  explanations  which  vary  with  the  nature  of  the 
malady,  the  degree  of  the  patient's  education  and  intelligence, 
and  the  current  ideas  of  the  times.  In  the  middle  ages 
psychosensory  disorders  were  often  attributed  to  diabolic 
intervention,  and  this  not  only  by  patients  but  also  by  their 
friends.  Patients  of  our  own  times  mostly  resort  for  ex- 
planations to  the  great  modern  inventions  (electric  currents, 
telephone,  X-rays,  wireless,  etc.).  Some  fancy  to  them- 
selves apparatus  or  imaginary  forces.  One  patient  attrib- 
uted his  disturbances  of  general  sensibility  to  a  ''  magneto- 

1  Johannes  Mueller.     Loc.  cit. 

2  Wernicke.     Grundriss  der  Psychiatrie,  p.  126. 


HALLUCINATIONS  25 

electro-psychologic  "  current.  Another  received  the  visions 
from  a  "  theologico-celestial  projector." 

Affedivitij. — Hallucinations  are  sometimes  agreeable, 
at  other  times  painful,  and  occasionally,  chiefly  in  dements, 
indifferent. 

In  the  first  case  their  outward  manifestations  are  an 
appearance  of  satisfaction,  an  expression  of  happiness, 
and  sometimes  ecstatic  attitudes. 

In  the  second  case,  which  is  the  more  frequent,  the 
patients  become  sad,  gloomy,  or,  on  the  contrary,  agitated 
and  violent,  a  prey  to  anxiety  or  anger. 

The  two  kinds  of  hallucinations,  agreeable  and  painful, 
are  occasionally  encountered  in  the  same  subject.  Some- 
times they  follow  each  other  without  any  regular  order  and 
are  coupled  with  a  variable  disposition  and  incoherent 
delusions,  as  in  maniacs  and  in  general  paralytics;  at 
other  times  they  follow  each  other  somewhat  systematic- 
ally— the  painful  hallucinations  are  combated  by  the  agree- 
able ones.  The  patients  often  speak  of  their  persecutors, 
who  insult,  threaten,  and  abuse  them,  and  of  their  defenders 
who  console  them,  reassure  them,  and  repair  the  damage 
done  by  the  former.  A  persecuted  patient  heard  a  voice 
call  her  ''a  slut";  immediately  another  voice  responded, 
"He  lies;  she  is  a  brave  woman."  Some  patients  tell 'of 
their  limbs  being  smashed  and  their  viscera  extracted  every 
night,  but  that  nevertheless  they  are  sound  and  safe  when 
they  arise,  thanks  to  the  good  offices  of  their  defenders, 
who  properly  replace  everything.  These  two  sets  of  hallu- 
cinations constitute  what  the  patients  sometimes  call  the 
attack  and  the  defense. 

The  indifferent  hallucinations  are  of  but  little  interest. 
They  are  met  with  at  the  terminal  periods  of  processes 
of  deterioration,  and  also  at  the  beginning  of  convalescence 
in  acute  psychoses.  In  the  latter  case  they  rapidly  become 
conscious  hallucinations  and  finally  disappear. 

Reactions. — The  influence  of  hallucinations  upon  the 
will  depends  upon  the  state  of  the  judgment  and  of  the 


26     SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

afifectivity.  If  the  judgment  is  sound,  if  the  hallucinations 
are  looked  upon  as  pathological  phenomena,  they  give  rise 
to  no  reaction;  and  the  same  is  the  case  when  they  make 
no  impression  upon  the  emotions. 

But  when  they  are  accepted  by  the  patient  as  real  per- 
ceptions and  influence  strongly  the  emotional  state,  hallu- 
cinations, on  the  contrary,  govern  the  will  to  a  very  con- 
siderable extent  and  prompt  the  patient  to  defend  himself 
against  the  ill-treatment  of  which  he  believes  himself  to  be 
the  object  or  to  obey  the  commands  which  are  given  him 
(imperative  hallucinations) .  Hence  the  frequency  of  violent 
and  criminal  acts  committed  by  the  insane,  and  the  well- 
known  axiom  in  psychiatry  according  to  which  all  subjects 
of  hallucinations  are  dangerous  patients.  Revington  has 
found,  from  a  study  of  forty-nine  cases  of  homicide  committed 
by  insane  patients,  that  in  most  instances  the  murder 
resulted  from  a  hallucination. ^ 

The  reactions  caused  by  hallucinations  are  often  abrupt, 
unreasonable,  and  of  an  impulsive  character,  especially 
in  the  feeble-minded  and  in  patients  with  profound  clouding 
of  consciousness  (delirium  tremens,  epileptic  delirium). 
But  they  may  also  show  all  the  evidences  of  careful  pre- 
meditation. Certain  persecuted  patients,  exasperated  by 
their  painful  hallucinations,  prepare  their  vengeance  with 
infinite  precaution. 

The  influence  of  hallucinations  upon  the  will  is  often 
so  powerful  that  nothing  can  combat  it,  neither  the  sense  of 
duty,  nor  the  love  of  family,  nor  even  the  instinct  of  self- 
preservation.  A  patient  passing  near  a  river  heard  a  voice 
tell  him:  "Throw  yourself  into  the  water."  He  obeyed 
without  hesitation,  and  to  justify  himself  declared  simply: 
"  They  told  me  to  do  it;  I  was  forced  to  obey." 

Combined  Hallucinations. — Sometimes  hallucinations 
affect  but  one  sense.  Such  are  the  hallucinations  of  hearing 
at  the  beginning  of  systematized  delusional  states.     Gen- 

1  Revington.  Mental  Conditions  Resulting  in  Homicide.  The 
Journ.  of  Ment.  Sc,  AprD,  1902. 


HALLUCINATIONS  27 

erally,  however,  the  pathological  disorder  affects  several 
senses,  the  different  hallucinations  either  following  one 
another,  or  existing  together  without  any  correlation,  or 
combining  themselves  and  producing  complex  scenes  either 
of  a  fantastic  aspect  or  analogous  to  real  life.  In  the  latter 
case  they  bear  the  name  of  combined  hallucinations.  The 
patient  sees  imaginary  persons,  hears  them  speak,  feels 
the  blows  that  they  inflict  upon  him,  makes  efforts  to  reject 
the  poisonous  substances  which  they  force  into  his  mouth, 
etc.  This  state,  closely  related  to  dreams,  is  always  accom- 
panied by  marked  clouding  of  consciousness. 

Diagnosis  of  Hallucinations. — Two  possibilities  may 
present  themselves:  (1)  the  patient  directly  informs  the 
physician  about  his  condition;  (2)  he  gives  no  information 
whatever,  either  because  of  his  reticence  or  because  of  his 
intellectual  obtuseness. 

In  the  first  case  the  diagnosis  of  hallucinations  is  generally 
easy.  It  is  necessary,  however,  to  ascertain  that  the  patho- 
logical phenomenon  is  really  a  hallucination,  and  not  an 
illusion;  in  other  words,  that  it  is  a  perception  without  an 
object,  and  not  an  inaccurate  perception.  Only  a  detailed 
examination  of  the  circumstances  under  which  the  phenom- 
enon shows  itself  may  prevent  an  error;  it  is  very  difficult 
indeed  when  a  subject  hears  himself  being  called  a  thief 
in  the  midst  of  thousands  of  street  noises,  to  decide  whether 
he  experiences  a  hallucination  or  an  illusion.  The  certainty 
is,  on  the  other  hand,  much  greater  when  the  morbid 
perception  occurs  in  absolute  silence,  as  during  the 
night. 

In  the  second  case  the  diagnosis  must  be  made  without 
the  assistance  of  the  patient,  or  even  in  spite  of  his  denials. 
It  must  be  based  only  upon  the  patient's  attitudes,  move- 
ments, and  at  times  upon  the  means  of  defense  to  which  he 
resorts  and  which  vary  according  to  the  sense  affected. 
The  ear  turned  for  some  time  in  a  certain  direction,  the 
eyes  fixed  or  following  a  definite  line  without  there  being 
any  real  object  to  attract  them,  the  ears  stuffed  with  foreign 


28       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

bodies,  evidences  of  strong  emotions,  an  expression  of  fear, 
etc.,  lead  to  the  presumption  of  the  existence  of  hallucina- 
tions. I  say  -presumftion  because  the  external  signs  do  not 
enable  us  to  establish  with  certainty  the  patient's  state  of 
consciousness.  Over-refined  psychological  analyses  are  to 
be  mistrusted  if  one  is  to  avoid  unwarranted  conclusions 
which  would  render  the  diagnosis  and  prognosis  faulty. 

Relations  between  Hallucinations  and  other  Mental 
Disorders. — What  position  do  hallucinations  occupy  in 
the  genesis  of  the  psychoses?  Are  they  primary  or  second- 
ary? 

It  is  not  impossible  that  at  times,  notably  in  the  in- 
toxications and  in  cases  of  localized  lesion,  hallucinations 
appear  first  and  are  the  cause  of  the  other  mental  disturb- 
ances which  follow.  In  practice,  however,  such  cases 
occur  but  rarely.  A  careful  and  complete  history  almost 
always  shows  that  the  hallucinations  are  preceded  by  other 
symptoms:  depression,  intellectual  obtuseness,  clouding 
of  consciousness,  delusions,  etc. 

Indeed  it  is  difficult  to  conceive  of  one  or  more  hallu- 
cinations appearing  in  a  person  free  from  all  other  mental 
trouble,  without  their  being  at  once  corrected  by  the  judg- 
ment aided  by  the  other  senses.  On  the  other  hand  it  is 
quite  intelligible  that  imaginary  perceptions  may  exercise 
an  influence  upon  the  attention,  the  emotions,  the  judg- 
ment, and  the  will,  if  they  are  but  the  reflection  or  the 
realization  of  the  patient's  preoccupations  and  morbid  ideas, 
that  is  to  say,  if  they  are  secondary.  The  melancholiac 
who  believes  himself  guilty  of  a  crime  sees  and  hears  the 
police  officers  who  are  coming  to  arrest  him.  The  paranoiac 
who  behoves  himself  to  be  exposed  to  the  malevolence  of 
his  imaginary  enemies  hears  their  voices  insulting  him. 
The  general  paralytic  with  pleasing  and  expansive  delusions 
experiences  pleasant  sensations.  Hallucinations  are,  then, 
an  expression,  and  not  a  cause,  of  delusions;  and  that 
is  why  they  harmonize  so  perfectly  with  the  mental  state  of 
the  subject. 


HALLUCINATIONS  29 

Some  psychiatrists  ^  have  described  a  hallucinatory  de- 
lirium as  a  distinct  morbid  entity  the  essential  features 
of  which  are  the  multipUcity  and  the  primary  character 
of  the  halkicinations.  If  the  idea  which  we  attempted 
to  convey  above  is  correct,  hallucinations,  never  or  almost 
never  being  primary,  cannot  form  the  essential  and  ex- 
clusive feature  of  an  affection,  and  hallucinatory  delirium 
cannot  retain  its  autonomy.  For  this  reason  most  authors 
classify  such  cases  with  confusional  psychoses,  general 
paralysis,  dementia  prsecox,  and  toxic  psychoses. 

General  Etiology  of  Hallucinations. — On  this  subject 
we  possess  but  very  incomplete  information. 

Hallucinations  appear  readily  in  states  of  impaired 
consciousness,  as  epileptic  delirium  and  the  toxic  psychoses. 
The  hallucinations  which  precede  sleep  in  certain  nervous 
subjects  are  most  frequently  of  the  conscious  type  and  are 
to  be  attributed  to  weakening  of  consciousness. 

Hallucinations  are  very  apt  to  appear  in  the  absence 
of  real  sensations — those  of  hearing  during  silence  and 
those  of  vision  in  darkness.  This  explains  why  isolation 
in  prison  cells  predisposes  to  hallucinatory  psychoses  (Kirn, 
Rudin).2 

In  some  instances  hallucinations  are  produced  in  a 
somewhat  automatic  manner,  at  the  occasion  of  some 
definite  impression.  One  patient  felt  a  taste  of  sulphur 
in  his  mouth  whenever  the  name  of  one  of  his  persecutors 
was  uttered  in  his  presence.  Such  hallucinations  have  been 
described  by  Kahlbaum  under  the  name  of  reflex  hallu- 
cinations. 

Hallucinations  may  depend  to  a  certain  extent  upon 
a  peripheral  excitation  either  of  the  sensory  organ  itself 
or  of  the  conducting  nerve.  They  are  in  such  cases  fre- 
quently unilateral.  "  Max  Busch  has  brought  about  a 
notable  improvement  in  the  mental  condition  of  a  patient 

^  Farnarier.     La  psychose  hallucinatoire,  Paris,  1899. 
2  Riidin.     Fine   Form   akuten   hallucinatorischen    Verfolgungswahns 
in  der  Haft,  etc.     Allg.  Zeitschr.  f.  Psychiat.,  1903. 


30       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

who  had  auditory  hallucinations  which  were  most  ma,rked 
on  the  left  side,  by  treating  his  otitis  media  with  perfora- 
tion of  the  drum  membrane,  which  he  had  contracted 
during  childhood."  ^  Visual  hallucinations  have  been  ob- 
served to  appear  as  the  result  of  ocular  lesions,  such  as  cata- 
ract, and  to  disappear  under  appropriate  treatment.  These 
peripheral  lesions  are,  so  to  speak,  but  a  pretext  for  the 
hallucinations,  and  are  not  to  be  considered  as  their  true 
cause.  The  cause  is  to  be  looked  for  in  a  special  state  of 
morbid  irritability  of  the  centers  of  perception  which  causes 
them  to  react  by  hallucinatory  phenomena  to  abnormal 
peripheral  excitation.^  Hallucinations  sometimes  occur  in 
cases  in  which  the  corresponding  ■  sensory  function  has 
been  lost  completely.  Thus  auditory  hallucinations  may 
be  associated  with  total  deafness,  unilateral  or  bilateral. 

Peripheral  hallucinations  are  very  analogous  to  Ijiep- 
mann's  phenomenon:  if  in  a  convalescent  alcoholic  slight 
pressure  is  made  upon  the  eyeballs,  hallucinations  are  some- 
times induced,  even  when  the  subject  does  not  any  more 
experience  them  spontaneously.  The  peripheral  excita- 
tion transmits  to  the  brain  nothing  but  a  nervous  discharge, 
the  clinical  expression  of  which  is  the  hallucination.  The 
fact  that  a  great  many  patients  present  very  grave  and  old 
standing  lesions  of  the  sensory  organs  without  having  any 
hallucinations  is  also  evidence  to  prove  that  these  affections 
are  of  but  secondary  importance  in  the  causation  of  psy- 
chosensory disorders. 

Finally,  hallucinations  may  be  induced  by  suggestion. 
Sometimes  it  suffices  merely  to  fix  the  attention  of  the 
patient  upon  a  certain  point  for  him  to  discover  imaginary 
objects,  persons,  or  forms.  Such  is  frequently  the  case  in 
toxic    states,    notably   alcoholism    and    cocainism,    also   in 

^  Quoted  by  Legay.  Essai  sur  les  rapports  de  Vorgane  auditif 
avec  les  hallucinations  de  I'ou'ie.     These  de  Paris,  1898,  p.  25. 

2  Joffroy.  Les  hallucinations  unilaterales.  Arch,  de  neurol.,  1896, 
No.  2. — Mariani.  Un  cas  d' hallucination  unilaterale.  Riforma  medica, 
1899,  Nos.  30  and  31. 


HALLUCINATIONS  31 

certain  dementias.  In  an  observation  kindly  communicated 
by  Thivet,  a  patient  read  whole  words  upon  a  blank  surface 
that  was  presented  to  him. 


B,     SPECIAL    FEATURES     OF    EACH     VARIETY    OF    HALLU- 
CINATIONS     • 

Hallucinations  of  Hearing. — In  pathological  states,  as 
in  the  normal  state,  auditory  sensations  occupy  a  position 
of  primary  importance  among  the  psychic  functions;  thus, 
of  all  hallucinations  those  of  hearing  are  clinically  the  most 
frequent  and  the  most  important. 

Seglas  ^  classifies  them  in  three  categories:  "Elemen- 
tary auditory  hallucinations,  consisting  of  simple  sounds; 
common  auditory  hallucinations,  consisting  of  sounds  refer- 
able to  definite  objects;  and  verbal  auditory  hallucinations, 
consisting  of  words  repesenting  ideas." 

Wernicke  2  combines  the  first  two  categories  under  the 
name  of  akoasms,  and  designates  the  third,  the  only  one  that 
seems  to  him  to  merit  separate  consideration,  by  the  name 
of  phonemes. 

Akoasms  comprise  imaginary  noises  of  a  variable  nature, 
such  as  buzzing,  whistling,  screaming,  groaning,  ringing  of 
bells,  explosions  of  firearms,  etc.  Their  clinical  significance 
is  the  same  as  that  of  hallucinations  in  general,  and  their 
influence  upon  the  mind  depends  upon  their  interpretation 
by  the  patient. 

Phonemes  (the  verbal  auditory  hallucinations  of  Seglas) 
have  on  the  contrary  a  special  significance,  inasmuch  as  they 
consist  of  "  words  representing  ideas."  Their  influence  is 
much  more  direct  and  much  more  powerful  than  that  of 
akoasms. 

^  Legons  cliniques  sur  les  maladies  mentales  et  nerveuses,  p.  5. — 
Pathogenie  et  physiologie  pathologique  de  V hallucination  de  Vouie. 
Congres  des  medecins  alienistes  et  neurologistes,  1897. 

"^Loc.  cit.,  p.  189. 


32       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

Their  content  varies  from  isolated  words  to  the  most 
compHcated  discourses.  Sometimes  the  words  or  phrases 
are  pronounced  indistinctly,  resembling  a  faint  murmur; 
at  other  times  they  are  perceived  with  remarkable  clearness. 
"  It  seems  to  me/'  patients  often  say,  "  that  somebody  is 
speaking  very  near  me.  .  .  .1  hear  my  enemies  as  well  as 
I  hear  you."  This  distinctness  largely  accounts  for  their 
being  accepted  as  real  voices,  and  explains  partly  the  re- 
markable influence  of  auditory  hallucinations. 

The  "  invisible  ones,"  as  the  patients  often  call  the 
imaginary  voices,  are  sometimes  localized  with  extraor- 
dinary precision.  "  The  insane  manifest  a  power  of  locah- 
zation  not  encountered  in  other  than  pathological  states."  ^ 
The  distance  at  which  they  beUeve  they  hear  the  voices  is 
very  variable;  the  voices  may  be  very  close  by  or,  on  the 
contrary,  hundreds  of  miles  away.  Many  patients  hold 
the  persons  that  are  around  them  responsible  for  the  hallu- 
cinations; thus  are  explained  some  of  the  sudden  assaults 
often  committed  by  such  patients.  Others  ascribe  their 
hallucinations  to  inanimate  objects.  One  patient  accused 
her  needle,  another  her  stockings.  Still  others  lay  the 
blame  upon  invisible  instruments  which  are  used  by  their 
enemies  (phonographs,  telephones,  megaphones,  etc.). 

Like  all  other  hallucinations,  those  of  hearing  vary  with 
the  nature  of  the  mental  trouble;  sad  in  the  painful  states, 
agreeable  and  cheerful  in  the  expansive  states.  Usually 
the  names  by  which  the  patients  designate  the  "  invisible 
ones  "  are  not  very  choice  ones,  consisting  chiefly  of  profane 
or  even  filthy  expressions.  Unpleasant  hallucinations  may 
alternate  with  agreeable  ones  in  the  manner  of  attack  and 
defense,  as  has  already  been  stated.  Sometimes  each  of  the 
two  varieties  of  hallucinations  is  perceived  by  only  one  ear. 

The  voices  may  repeat  the   thoughts  of  the   patient, 

even  before  he  has  a  chance  to  express    them.      "  They 

know  before  I  do  what  reply  I  wish  to  make,"  said  one  such 

patient.     Another  said :  "  When  I  read  they  read  at  the  same 

1  Wernicke.     Loc.  cit.,  p.  205. 


HALLUCINATIONS  33 

time  and  repeat  every  word."  Many  complain  that  their 
thoughts  are  stolen  from  them.^ 

Quite  often  the  voices  create  neologisms  the  meaning 
of  which  may  remain  absolutely  enigmatical  to  the  patient 
himself,  or  to  which  hS  may  attribute  a  significance  which 
harmonizes  with  his  psychic  state. 

The  timbre  of  the  voices  is  very  variable.  In  some 
cases  the  patient  always  perceives  one  and  the  same  voice; 
but  more  frequently  many  voices  are  heard:  voices  of  men, 
women,  and  children,  which  are  sometimes  unknown  to  the 
patient,  at  other  times  familiar,  enabling  him  to  establish 
the  identity  of  his  persecutors. 

Although  they  are  encountered  in  a  great  many  mental 
affections,  acute  and  chronic,  hallucinations  of  hearing, 
if  they  constitute  a  prominent  feature  by  reason  of  their 
multiplicity,  distinctness,  or  intensity,  usually  point  to  a 
grave  prognosis.  Their  occurrence  in  an  acute  psychosis 
often  forebodes  a  particularly  long  duration  of  the  disease. 

Hallucinations  of  Sight. — Hallucinations  of  sight  chiefly 
occur  in  toxic  and  febrile  deliria. 

They  vary  greatly  in  distinctness.  At  times  they  are 
so  clear  that  the  patient  is  able  to  make  a  sketch  of  them; 
often  they  are,  on  the  contrary,  vague  and  uncertain. 

Like  the  voices,  the  visions  are  apt  to  be  taken  for  reality 
by  the  subject;  he  seeks  to  remove  them,  to  shun  them,  or 
on  the  contrary  to  seize  them.  They  are  in  such  cases  coupled 
with  more  or  less  marked  clouding  of  consciousness. 

Many  patients,  on  the  contrary,  consider  their  hallu- 
cinations as  artificial  phenomena.  The  more  conscious  and 
the  clearer  in  mind  the  patient  is,  the  more  apt  he  is  to 
recognize  the  difference  between  the  real  world  and  his 
visions,  because,  with  the  exception  of  the  cases  in  which 
consciousness  is  profoundly  disordered,  visual  hallucinations 
"  seldom  bear  the  appearance  of  reality."  ^     They  lack  the 

^  Bechterew.  Ueber  das  Horen  der  eigenen  Gedanken.  Arch.  f. 
Psychiatrie,  Vol.  XXX. 

2  Wernicke.     Loc.  cit.,  p.  194. 


34       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

proper  qualities  of  normal  visual  sensations:  perspective, 
clearness  of  contour,  variety  of  tints,  etc.  Often  the  morbid 
image  appears  in  a  single  plane,  hazy  in  outline,  and  grayish 
in  color.  It  is  therefore  not  surprising  that,  not  possessing 
the  attributes  of  true  perceptions,  visual  hallucinations  are 
often  not  taken  for  reality,  and  do  not  exercise  upon  the 
mind  of  the  patient  the  same  degree  of  influence  as  do 
phonemes. 

Some  patients  consider  their  hallucinations  as  shadows 
or  images  which  they  are  made  to  see  artificially  by  means 
of  projecting  apparatus,  electric  currents,  etc.  Others 
attribute  them  to  the  pernicious  action  of  poisons  which 
their  enemies  make  them  absorb. 

Visual  hallucinations  may  take  the  form,  though  rarely, 
of  verbal  hallucinations  of  vision.  The  patients  see  words 
and  phrases  on  tables,  walls,  etc.  A  subject  of  choreic 
insanity  observed  in  Joffroy's  clinic  saw  her  own  name 
written  on  her  apron.  Everybody  is  familiar  with  the  famous 
words  Mene,  mene,  tekel,  upharsin,  which  the  guests  saw 
appear  upon  the  wall  at  Belshazzar's  feast. 

Hallucinations  of  Taste  and  Smell. — The  senses  of 
taste  and  smell  are  as  closely  associated  in  pathological 
states  as  they  are  in  the  normal  state.  Therefore  halluci- 
nations of  these  senses  are  usually  considered  together. 

Their  clinical  significance  varies,  depending  upon  whether 
they  coexist  with  psychic  and  somatic  disorders  of  an 
acute  nature,  or  whether  they  appear  in  the  course  of  a 
chronic  psychosis. 

In  the  first  case  they  often  result  from  dryness  and 
inflammation  of  the  nasal  and  buccal  mucous  membranes 
or  glands.  They  disappear  with  the  disturbances  of  these 
glands,  and  they  may  be  modified  very  favorably  by  appro- 
priate treatment.  Their  importance  with  regard  to  prog- 
nosis in  such  cases  is  very  slight. 

It  is  altogether  different  in  the  second  case,  when  they 
supervene  independently  of  the  above  causes  in  the  course 
of    chronic    psychoses.     They    almost    always    indicate    a 


HALLUCINATIONS  35 

profound  alteration  of  personality  and  progress  toward 
dementia. 

Hallucinations  of  taste  and  smell  are  mostly  unpleasant. 
The  patients  complain  of  nauseating  odors;  putrid  emana- 
tions are  blown  toward  them;  they  are  made  to  eat  fecal 
matter;  poisons  are  poured  into  their  mouth,  etc.  They 
make  use  of  certain  means  of  defense,  such  as  spitting, 
stuffing  the  nostrils  with  cotton  or  paper,  and,  what  con- 
stitutes a  very  grave  symptom,  refusal  of  food. 

Hallucinations  of  Touch,  Thermal  Sense,  and  Sense  of 
Pain. — These  are  often  placed  in  a  single  group  under 
the  name  of  hallucinations  of  general  sensibility. 

Hallucinations  of  touch  are  frequent  in  certain  toxic 
psychoses  (delirium  tremens,  cocaine  delirium),  and  in 
chronic  delusional  states.  The  patients  feel  the  breath  of 
somebody  or  the  contact  of  something;  they  feel  as  though 
spiders  are  crawling  upon  their  bodies,  or  they  may  have  a 
sensation  of  being  bound  in  an  entangled  mass  of  cords. 

Closely  related  to  the  above  are  hallucinations  of  the 
genital  sense,  which  are  encountered  in  mania,  and  in  many 
other  acute  and  chronic  psychoses.  They  consist  of  either 
painful  or  voluptuous  imaginary  sensations.  When  they 
coexist  with  perfect  lucidity  they  generally  indicate  a  very 
grave  prognosis. 

Hallucinations  of  the  thermal  sense  and  of  the  sense  of 
pain  are  a  feature  of  chronic  delusional  states.  The  patients 
complain  of  being  burned  alive,  that  their  body  is  being 
pierced  with  a  red-hot  iron,  that  they  are  being  thrown 
off  from  their  chair,  that  they  are  made  to  experience  shocks 
like  those  of  electric  discharges,  etc. 

Motor  Hallucinations. — A  motor  hallucination  may  be 
defined  as  an  imaginary  perception  of  a  movement.  It 
constitutes  a  disorder  of  that  kind  of  sensibility  which 
has  been  designated  by  the  term  muscular  sense. 

Analogous  phenomena  are  encountered  in  normal  per- 
sons, the  sensation  of  heaviness  or  of  lightness  of  the  limbs, 
which  we  experience  during  sleep,  are  justly  attributed  by 


36       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

Beaunis  ^  to  disturbances  of  the  muscular  sense;  the 
illusions  referred  to  an  amputated  limh  are  often  accompanied 
by  motor  hallucinations. 

Motor  hallucinations  are  frequent  in  psychotics.  Some 
feel  themselves  being  raised  from  their  bed,  shaken  con- 
tinually against  their  will,  etc.  Others,  like  mediaeval 
sorcerers,  imagine  themselves  flying  through  the  air. 

By  a  well-known  psychological  process  the  sensation 
tends  to  transform  itself  into  an  act,  the  motor  image  into 
a  movement.  The  motor  hallucination  becomes  an  impulse. 
The  patient  feels  with  astonishment  that  his  limbs,  his 
tongue,  or  his  mouth  become  the  seat  of  movement  in  which 
his  will  takes  no  part.  A  patient  of  Krishaber's,  for  instance, 
felt  his  legs  "  move  as  though  endowed  with  a  power  other 
than  that  of  his  own  will."  Many  persecuted  or  mystic 
patients  affirm  that  they  have  been  transformed  into  autom- 
atons, and  that  God  or  their  enemies,  as  the  case  may  be, 
make  them  go  and  act  as  they  wish. 

There  is  a  certain  form  of  motor  hallucinations  which 
deserves  particular  attention  by  reason  of  its  frequency, 
its  clinical  importance,  and  its  high  psychological  interest; 
these  are  the  verbal  motor  hallucinations  which  have  been 
admirably  described  by  Seglas.^  As  their  name  indicates, 
they  affect  the  function  of  speech.  The  patient  is  conscious 
of  involuntary  movements  of  his  tongue  and  Hps,  identical 
with  those  which  produce  articulation  of  words.  The  sensa- 
tion may  exist  alone  or  it  may  acquire  such  intensity  that 
it  is  transformed  into  actual  motion,  and  the  patient  begins 
to  speak  in  spite  of  himself.  Often  the  pathological  move- 
ments are  scarcely  apparent,  being  Hmited  to  an  inaudible 
whisper.  Sometimes  the  impulse  is  so  strong  that  it  results 
in  loud  talking  or  screaming.  The  remarks  made  by  the 
patient  in  such  a  case  may  be  entirely  discordant  with  his 
true  sentiments.     In  this  way  such  patients  may  uninten- 

1  Les  sensations  internes,  1889,  Paris,  F.  Alcan. 

2  Legons  diniques.     Also  Les  troubles  du  langage  chez  les  alienes. 
(Bibliotheque  Charcot-Debove.) 


HALLUCINATIONS  37 

tionally  insult  their  relatives,  making  use  of  obscene  language, 
blasphemies,  etc.  At  other  times  the  thoughts  of  the  patient 
are  spoken  out  in  spite  of  himself.  Pierracini  has  termed 
this  phenomenon  "  the  escape  of  thought."  (Quoted  by 
Scglas.) 

Verbal  motor  hallucinations  exercise  upon  the  function 
of  speech,  even  in  those  cases  in  which  they  do  not  reach 
the  stage  of  actual  articulatory  movements,  so  powerful 
an  inhibitory  influence  that  the  subject  becomes  totally 
unable  to  speak.  This  is  in  perfect  accord  with  the  obser- 
vation of  Strieker,  who  found  that  two  verbal  motor  images 
cannot  exist  at  the  same  tune.  Already  occupied  by  the 
hallucinatory  motor  image,  consciousness  remains  closed 
to  normal  motor  images.  Verbal  motor  hallucinations  are 
thus  a  cause  of  77iutism. 

Graphic  motor  hallucinations  affect  written  speech. 
"  The  graphic  image  then  comes  into  play,  and  in  con- 
sequence of  the  morbid  irritabihty  of  the  special  cortical 
center  for  written  speech  the  patient  has  the  exact  per- 
ception of  a  word  with  the  aid  of  the  representations  of  the 
coordinate  movements  which  would  accompany  it  if  he  were 
really  writing  the  word."  ^ 

When  this  morbid  irritation  attains  a  certain  degree 
of  intensity  the  hallucination  becomes  a  graphic  impulse 
and  gives  rise  to  automatic  writing,  which  is  often  met 
with  in  "'  writing  mediums." 

The  interpretation  of  motor  hallucinations  varies  in 
different  patients.  Some  complain  that  thek  enemies 
govern  their  tongues  by  means  of  invisible  wires.  Others, 
feeling  themselves  no  longer  masters  of  their  own  organs, 
are  naturally  led  to  think  that  a  strange  personahty  has 
become  established  beside  them.  Some  of  the  ''  possessed  " 
of  mediaeval  times  imdoubtedly  had  motor  hallucinations. 

Motor  hallucinations  generally  imply  a  grai'e  prog- 
nosis. They  indicate  an  already  advanced  disaggregation 
of  the  personality.  Accordingly  they  are  chiefly  encoimtered 
^  Seglas.     Les  troubles  du  langage,  p.  246. 


38       SYMPTOMATOLOGY— DISORDERS  OF  PERCEPTION 

in  the  chronic  psychoses;  they  may  appear,  however,  in 
certain  acute  psychoses,  such  as  melanchoha  (Seglas)  and 
alcohoHc  delusional  states  (Vallon,  Cololian).^ 

Theories  of  Hallucinations. — Johannes  Mueller  was  of 
the  opinion  that  hallucinations  are  the  consequence  of 
abnormal  irritation  of  peripheral  sensory  organs. 

According  to  Meynert  they  result  from  automatic 
activity  of  subcortical  cerebral  centers,  which  are  no  longer 
inhibited  by  the  cerebral  cortex  as  they  are  in  the  normal 
state. 

The  primary  cause  of  hallucinations  would  thus  be  a 
suppression  of  the  inhibitory  power  of  the  cortex,  which 
is  one  of  the  manifestations  of  cortical  paralysis.  The 
hallucination  is  then  the  consequence  of  a  supremacy  of 
lower  cerebral  functions  over  higher  ones. 

Finally,  according  to  Tambourini,  hallucinations  are 
produced  by  the  automatic  activity  of  a  psychosensory  pro- 
jection-center. 

Under  what  conditions  does  the  automatism  of  the 
projection-center  come  into  play?  Is  it  under  the  influence 
of  direct  irritation  resulting,  for  instance,  from  a  tumor  or 
from  a  circumscribed  patch  of  meningitis  localized  exactly 
at  this  center?  Such  cases  have  occurred.  Serieux  ^  has 
observed  verbal  motor  hallucinations  in  a  general  paralytic 
in  whose  case  the  autopsy  showed  a  predominance  of  the 
lesions  of  meningo-encephalitis  at  the  level  of  the  lower 
portion  of  the  left  third  frontal  convolution.  The  lesion 
must  not,  however,  be  a  too  destructive  one.  "  Indeed, 
for  a  center  to  be  able  to  produce  hallucinations,  it  is  neces- 
sary that  conditions  of  integrity  be  preserved  sufficient  to 
permit  its  activity  "  (Joffroy).^ 

1  Cololian.  Les  hallucinations  psycho-motrices  verbales  dans  I'alco- 
olisme.     Arch,  de  Neurol.,  Nov.,  1899. 

2  Sur  un  cas  d'hallucination  motrice  verbale  chez  une  paralytique 
generate.     Bull,  de  la  soc.  de  med.  ment.  de  Belgique,  1894. 

'  Les  hallucinations  unilaterales. — Siebert  has  also  reported  a  case 
in  which  very  pronounced  haUuciuations  of  the  sense  of  smell  per- 
sisted for  a  long  time  and  subsequently  disappeared  by  degrees.     At 


HALLUCINATIONS  39 

Most  frequently,  however,  the  center  of  projection  is 
not  the  seat  of  any  demonstrable  lesion.  It  seems,  then, 
that  in  most  cases  the  hallucinations  are  the  consequence, 
not  of  a  direct  irritation  of  the  psychosensory  center  itself, 
but  rather  of  an  indirect  irritation  coming  from  another 
portion  of  the  cortex.  This  explains  why  hallucinations  are 
always  a  secondary  phenomenon,  and  why  they  are  but  an 
expression,  a  reflection  of  the  pathological  preoccupations 
of  the  patient. 

Wernicke  has  conceived  a  very  ingenious  theory  of 
hallucinations,  founded  upon  his  general  hypothesis  of 
se junction.  By  this  term  he  designates  a  temporary  or 
permanent  interruption  of  the  paths  followed  normally  by 
a  nervous  impulse.  This  impulse  cannot  pass  on  freely, 
and  accumulates  above  the  point  of  the  lesion  like  the  water 
in  a  river  above  a  dam.  When  this  accumulation  occurs  in 
a  psychosensory  projection-center  it  sets  up  there  a  state  of 
abnormal  irritation  of  which  the  clinical  expression  is  a 
hallucination. 

the  autopsy  the  hippocampus  was  found  to  be  destroyed  by  a  tumor. 
The  author  supposes  that  the  hallucinations  were  caused  by  irrita- 
tion of  the  center  in  question  by  the  growth,  and  that  they  did  not 
cease  until  this  center  was  destroyed.  (Monatschr.  fiir  Psych,  u. 
Neurol.,  Vol.  VI.) 


CHAPTER  III 

SYMPTOMATOLOGY  {Continued) 

CONSCIO  USNESS— MEMORY— VOL  UNTARY  ASSOCIA  TION 
OF  IDEAS^ATTENTION— AUTOMATIC  ASSOCIATION 
OF  IDEAS— JUDGMENT 

§  1.    Disorders  of  Consciousness 

Consciousness  may  be  lost:  unconsciousness;  or  weak- 
ened :   clouding  of  consciousness. 

Unconsciousness  and  Clouding  of  Consciousness. — 
Unconsciousness  exists  physiologically  in  dreamless "  sleep, 
and  pathologically  in  coma  and  in  complete  stupor. 

Clouding  of  consciousness  represents  the  fundamental 
element  of  many  psychoses.  It  is  always  coupled  with 
more  or  less  complete  disorientation. 

A  complete  orientation  implies  the  integrity  of  the  fol- 
lowing three  notions: 

1.  The  notion  of  our  own  personality  (autopsychic 
orientation  of  Wernicke); 

2.  The  notion  of  the  external  world  (allopsychic  orienta- 
tion of  the  same  author) ;  • 

3.  The  notion  of  time. 

These  three  notions  may  disappear  together  or  singly. 
We  shall  see  later  that  in  certain  affections,  notably  in 
delirium  tremens,  the  orientation  of  time  and  p^.ace  is  lost, 
while  that  of  personality  remains  intact.  The  patient  is 
ignorant  of  the  fact  that  he  is  in  a  hospital  ward,  does  not 
appreciate  his  surroundings,  and  cannot  give  even  approxi- 
mately the  real  date.    But  he  knows  that  he  is  Mr.  X., 

40 


DISORDERS  OF  CONSCIOUSNESS  41 

following  such  and  such  an  occupation,  so  and  so  many- 
years  old,  born  on  such  and  such  a  day,  etc. 

Allopsychic  disorientation,  or  loss  of  the  notion  of  the 
external  world,  is  often  coupled  with  many  hallucinations. 
Some  authors  see  in  the  two  symptoms  a  causative  relation; 
the  hallucinations  transport  the  patient  to  an  imaginary 
world,  thus  making  him  lose  the  notion  of  the  real  world. 
Experience  does  not  bear  out  this  hypothesis:  (1)  because 
the  orientation  may  be  perfectly  preserved  in  spite  of  intense 
and  unceasing  hallucinations;  (2)  because,  inversely,  it  may 
be  profoundly  disordered  without  there  being  hallucinations 
of  any  kind ;  (3)  because  in  most  of  the  cases  in  which  these 
two  symptoms  are  associated  the  disorientation  precedes 
the  psychosensory  disturbances. 

Influence  of  Clouding  of  Consciousness  upon  the  Emo- 
tions and  upon  the  P..eactlons. — Unconsciousness  and  cloud- 
ing of  consciousness  find  expression,  in  the  emotional  sphere, 
in  indifference  and  dullness;  and,  in  the  psychomotor 
sphere,  in  aboulia  which  in  extreme  cases  may  amount  to 
complete  inaction. 

If  complicated  by  symptoms  of  excitement,  hallucinations 
and  illusions,  delusions,  or  anxiety,  clouding  of  consciousness 
is  accompanied  by  emotional  phenomena  and  reactions 
characteristic  of  these  symptoms.  It  is  important  to 
remember  above  all  that  the  disorder  of  consciousness  may 
impart  to  the  reactions  of  the  patient  a  more  or  less  impulsive 
character;  hence  their  brutal  and  sometimes  ferocious 
nature. 

Diagnosis  of  Clouding  of  Consciousness. — Unconscious- 
ness is  generally  apparent  from  the  absolute  indifference  of 
the  subject  who  fails  to  react  even  to  the  strongest  stimula- 
tion. However,  it  is  necessary  to  exercise  great  caution 
in  many  cases.  We  shall  see  later  on  that  certain  patients, 
the  catatonics,  present  every  appearance  of  "unconsciousness 
and  may  nevertheless  preserve  perfect  lucidity;  the  dis- 
order of  consciousness  is  here  only  a  seeming  one.  Often 
one  is  obliged  to  wait  before  coming  to  a  decision ;  when  the 


42  SYMPTOMATOLOGY 

attack  passes  off,  the  patient  himself  may  tell  of  his  former 
condition,  either  declaring  that  he  has  no  recollection  of  what 
passed  during  the  attack — in  which  case  the  unconsciousness 
was  real — or  explaining  that,  though  perceiving  external 
impressions,  he  was  unable  to  react — in  which  case  the  un- 
consciousness was  but  a  seeming  one. 

Clouding  of  consciousness  is  determined  by  putting  to 
the  subject  a  series  of  questions  concerning  his  age,  occupa- 
tion, the  date,  the  surroundings,  and  the  persons  about  him. 

States  of  Obscuration. — By  this  term  are  designated 
those  pathological  states  in  which  lowered  consciousness 
is  the  dominant  feature.  States  of  obscuration  vary  greatly 
in  their  aspect,  and  probably  also  in  their  nature.  All, 
however,  possess  one  feature  in  common:  they  leave  behind 
almost  complete  amnesia  for  the  occurrences  that  have 
taken  place  during  their  entire  duration.  But  the  degree 
of  consciousness  at  the  time  of  the  attack  itself  is  very 
difficult  to  determine,  and  probably  varies  greatly. 

Often  patients  afflicted  with  violent  delirium  have  but 
an  extremely  confused  notion  of  their  surroundings,  and  their 
acts  bear  the  character  of  complete  automatism.  Such 
are  cases  of  epileptic  delirium. 

Others,  on  the  contrary,  perform  complicated  acts,  such, 
for  instance,  as  are  involved  in  a  long  voyage,  in  a  sober 
and  reasonable  manner  and  without  attracting  anybody's 
attention;  and  still  they  may  have  no  subsequent  recol- 
lection of  these  acts.  This  occurs  in  certain  pathological 
absences  which  are  most  commonly  observed  in  epilepsy 
but  which  may  also  be  encountered  in  various  psychoses. 

It  can  scarcely  be  assumed  that  in  these  two  cases  the 
disorders  of  consciousness  are  identical. 

§  2.     Disorders  of  Memory 

An  act  of  memory  comprises  three  distinct  operations: 

1.  The  fixation  of  a  representation; 

2.  Its  conservation; 


DISORDERS  OF  MEMORY  43 

3.  Its  revival,  that  is  to  say,  its  reappearance  in  the  field 
of  consciousness. 

These  may  be  disordered  together  or  singly;  hence  the 
three  forms  of  amnesia: 

A.  Amnesia  by  default  of  fixation  (or  simply  amnesia  of 
fixation),  also  known  as  anterograde  amnesia; 

B.  Amnesia  of  conservation; 

C.  Amnesia  of  reproduction. 

The  latter  two  affect  impressions  previously  acquired 
and  constitute  retrograde  amnesia;  there  are  therefore 
two  varieties  of  retrograde  amnesia:  (1)  by  default  of  con- 
servation, and  (2)  by  default  of  reproduction. 

A.  Amnesia  of  Fixation:  Anterograde  Amnesia. — The 
power  of  fixation  (Merkfdhigkeit  of  German  authors)  is 
dependent  upon  the  distinctness  of  the  perceptions.  There- 
fore all  conditions  in  which  perceptions  are  vague  and 
uncertain  are  accompanied  by  a  more  or  less  marked  amnesia 
of  fixation;  such  is  the  case  in  epileptic  deliria  and  in  acute 
confusional  psychoses. 

Distinctness  of  perception  is  therefore  a  condition 
necessary  for  the  normal  working  of  memory;  it  is,  however, 
not  in  itself  a  sufficient  condition.  An  impression,  though 
very  clear  and  very  precise  at  the  moment,  may  not 
become  fixed  in  the  mind.  Thus  a  patient  with  polyneuritic 
psychosis  may  understand  perfectly  the  questions  put  to 
him,  execute  properly  the  orders  that  are  given  him,  so 
that  on  a  superficial  examination  he  may  convey  the  impres- 
sion of  a  normal  person;  but  he  preserves  an  incomplete 
recollection,  or  none  at  all,  of  the  occurrences  of  the  whole 
period  of  his  illness.  It  seems,  then,  that  for  proper  fixation 
is  required,  besides  sufficient  distinctness  of  perception, 
some  other  condition  the  nature  of  which  is  as  yet  undeter- 
mined. 

B.  Retrograde  Amnesia  by  Default  of  Conservation. — 
An  impression  fixed  in  memory  is  preserved  for  a  greater  or 
lesser  length  of  time,  depending  upon  its  nature  and  upon  the 
individual  capabilities  of  the  subject.     The  memory  of  an 


44  SYMPTOMATOLOGY 

important  event  persists  longer  than  that  of  an  insignificant 
one.  Certain  individuals  possess  a  prodigious  memory, 
others  a  very  poor  one  or  almost  none  at  all;  between  these 
two  extremes  there  are  infinite  gradations. 

The  disappearance,  under  the  influence  of  some  patho- 
logical cause,  of  impressions  previously  acquired,  constitutes 
what  we  have  termed  amnesia  of  conservation.  This  de- 
strudive,  and  consequently  incurable,  form  of  amnesia  is 
the  principal  factor  of  certain  types  of  dementia,  and  is  often 
the  first  sign  that  warns  the  patient's  relatives  of  the  begin- 
ning condition. 

The  disappearance  of  impressions  may  be  more  or  less 
complete,  depending  upon  the  nature  of  the  dementing 
process.  While  many  precocious  dements  for  a  long  time 
preserve  a  relatively  good  memoiy,  general  paralytics  and 
senile  dements  present  from  the  beginning  of  their  illness 
marked  amnesia. 

Amnesia  of  conserv^ation  is  generally  associated  with 
the  other  two  forms  of  amnesia:  amnesia  of  fixation  and 
amnesia  of  reproduction. 

C.  Retrograde  Amnesia  by  Default  of  Reproduction. — 
In  the  normal  state  an  impression  fixed  and  preserved 
in  memory  possesses  the  propertj^  of  being  revived  under 
certain  conditions.  In  pathological  conditions  this  power 
of  reproduction  may  be  suspended:  the  impressions  exist, 
but  they  are  dormant  and  cannot  be  revived.  This  form  of 
amnesia  is  encountered  in  many  acute  psychoses,  notably 
in  manic  depressive,  acute  confusional,  and  toxic  psychoses. 
Its  prognosis  is  of  course  much  more  favorable  than  is  that  of 
the  preceding  form. 

The  Course  of  Amnesia. — The  onset  may  be  sudden  or 
insidious;  it  is  often  sudden  in  amnesia  of  reproduction 
— pure  or  associated  with  amnesia  of  fixation — and  almost 
always  insidious  in  amnesia  of  conservation. 

Amnesia  may  be  stationary,  retrogressive,  or  progressive; 
it  is  stationary  when,  certain  impressions  having  become  de- 
stroyed, the  defect  persists  without  increasing;  retrogressive 


DISORDERS  OF  MEMORY  45 

when  the  impressions,  simply  dormant,  reappear  little  by 
little;  and  progressive  when,  as  the  pathological  process 
advances,  the  nmnber  of  destroyed  impressions  becomes 
greater  from  day  to  day. 

In  progressive  amnesia  the  disappearance  of  impressions 
occurs  not  at  random,  but  in  a  definite  order.  "  The  pro- 
gressive destruction  of  memory  follows  a  logical  course,  a 
law.  It  descends  progressively  from  the  unstable  to  the  stable: 
it  begins  with  recent  impressions  which,  fixed  imperfectly 
upon  the  nervous  elements,  seldom  repeated  and  therefore 
but  feebly  associated  with  others,  represent  the  organiza- 
tion in  its  weakest  degree;  it  ends  with  that  instinctive, 
sensory  memory  which,  stably  fixed  in  the  organism  and 
having  become  almost  an  integral  part  of  it,  represents  the 
organization  in  its  strongest  degree.  From  the  beginning 
to  the  end  the  course  of  amnesia,  governed  by  the  nature  of 
things,  follows  the  line  of  least  resistance,  that  is  to  say,  the 
line  of  least  organization.''  ^  In  senile  dementia,  in  which 
the  law  of  amnesia  is  most  perfectly  demonstrated,  the 
impressions  of  old  age  are  the  first  to  become  effaced,  later 
those  of  adult  life,  and  finally  those  of  youth  and  childhood. 
Some  of  the  latter  may  remain  intact  long  after  the  general 
ruin  of  memory  and  other  faculties.  It  is  not  uncommon  to 
meet  with  advanced  senile  dements  who,  though  incapable 
of  recollecting  the  existence  of  their  wife  and  children,  are 
still  able  to  relate  with  minute  details  the  occurrences  of  their 
childhood  or  to  recite  correctly  fragments  from  the  works  of 
classic  authors. 

The  law  of  amnesia,  though  always  the  same,  is  difficult 
to  demonstrate  in  those  affections  in  which  the  destruc- 
tion of  memory  progresses  very  rapidly,  where  many  im- 
pressions, like  other  manifestations  of  intellectual  life,  dis- 
appear en  masse.  In  general  paralysis  the  course  of  amnesia 
is  much  more  rapid  and  much  less  regular  than  in  senile 
dementia.  This  fact,  as  we  shall  see,  is  an  important  element 
in  diagnosis. 

1  Ribot.     The  Diseases  of  Memory. 


46  SYMPTOMATOLOGY 

Varieties  of  Amnesia. — ^Amnesia  is  said  to  be  partial 
when  it  involves  only  one  class  of  impressions,  for  instance 
proper  names,  numbers,  certain  special  branches  of  knowl- 
edge (music,  mathematics),  or  a  foreign  language.  A  young 
man  coming  out  of  a  severe  attack  of  typhoid  fever  forgot 
completely  the  English  language,  which  he  had  spoken 
fluently  before  the  onset  of  his  illness;  other  impressions 
were  quite  well  preserved.  When  it  involves  verbal  images 
the  amnesia  determines  a  particular  form  of  aphasia,  amnesic 
aphasia. 

Amnesia  is  general  when  it  affects  equally  all  classes  of 
impressions.     j\Iost  of  the  progressive  amnesias  are  general. 

Amnesia  may  be  limited  to  a  certain  period  of  existence. 
In  such  cases  its  onset  is  almost  always  sudden,  and  it  is 
either  anterograde,  or  retrograde  by  default  of  reproduction. 

Localization  of  Recollections. — A  recollection  of  an 
occurrence,  once  evoked,  is  usually  easily  localized  by 
us  as  to  its  position  in  the  past.  This  power  of  localization 
disappears  in  certain  psychoses.  The  patients  cannot  tell 
on  what  date  or  even  in  what  year  some  event  occurred, 
an  impression  of  which  they  have,  however,  preserved.  The 
default  of  localization  in  the  past  combined  with  a  certain 
degree  of  anterograde  and  retrograde  amnesia  produces 
disorientation  of  time. 

Illusions  and  Hallucinations  of  Memory. — In  an  illusion 
of  memory  a  past  event  presents  itself  to  consciousness  altered 
in  its  details  and  in  its  relation  to  the  patient,  and  exag- 
gerated or  diminished  in  importance.  Thus  one  senile 
dement  claimed  to  have  superintended  the  construction  of 
a  Gothic  cathedral  several  centuries  old,  holding,  as  he  said, 
"  the  calipers  in  one  hand  and  the  musket  m  the  other  to 
defend  myseK  against  the  Saracens."  Upon  inquiry  it  was 
found  that  the  patient  had  really  worked  about  thirty 
years  previously  on  the  restoration  of  an  old  cathedral. 

An  illusion  of  memory  becomes  a  true  hallucination 
when  the  representation  perceived  as  a  recollection  does  not 
correspond  to  any  actual  past  occurrence.     A  patient  who 


DISORDERS  OF  MEMORY  47 

had  been  in  bed  during  several  weeks  related  once  that  on 
the  previous  day  he  assisted  at  the  coronation  of  the  Russian 
emperor:  this  is  a  representation  without  an  object,  a 
hallucination  of  memory. 

Illusions  and  hallucinations  of  memory  form  the  basis 
of  pseudo-reminiscences  which  are  met  with  in  many 
psychoses,  especially  in  the  polyneuritic  psychosis. 

Pseudo-reminiscences  are  not  infrequent  in  certain 
persons  who  are  usually  not  classed  with  psychotics.  In 
such  cases  the  hallucinations  and  illusions  of  memory  occur 
on  a  basis  of  abnormally  vivid  mental  images  which  an 
inadequate  auto-critique  fails  to  correct.^  -^"| 

In  some  cases  pseudo-reminiscences  occur  in  such  abun- 
dance as  to  constitute  the  principal  symptom  of  the  disease. 
Thus  one  patient  imagined  himself  to  have  participated  in 
all  the  important  historical  events  of  his  epoch,  particularly 
in  the  great  military  actions.  He  had  taken  part  succes- 
sively in  the  campaigns  of  Tonquin,  Madagascar,  and 
Dahomey,  also  in  the  Spanish-American  war  and  in  the 
Boer  war,  serving  in  different  grades — now  as  corporal, 
now  as  sergeant-major,  now  as  colonel.  During  all  that 
time  he  had  had  several  conferences  with  the  German 
emperor,  also  with  the  empress,  his  cousin.  When  his 
reminiscence  had  bearing  upon  some  historical  event  the 
patient  would  give  details  culled  from  magazines  or  from 
popular  books,  and  related  them  with  a  degree  of  accuracy 
which  indicated  a  good  memory. 

We  would  mention  lastly  a  curious  form  of  illusion  of 
memory,  which  has  been  designated  by  the  expression 
illusion  of  having  already  seen.  "  It  consists  in  a  belief  that 
a  state  of  consciousness  that  in  reality  is  new  was  experienced 
before,  so  that  when  it  first  occurs  it  is  thought  to  be  a 
repetition."  ^     One  patient  claimed  that  all  the  occurrences 

^  Delbriick.  Die  pathologische  Luge  und  die  psychisch  abnormen 
Schwindler. — Koeppen.  Ueber  die  pathologische  Liige  (Pseudologia 
phantastica) .     Charite  Annal.,  Jan.,  1898. 

2  Ribot.     Loc.  cit. 


48  SYMPTOMATOLOGY 

which  he  was  witnessing  had  taken  place  a  year  previously, 
day  by  day.  He  made  a  great  deal  of  noise  at  the  marriage 
of  one  of  his  sisters,  demanding  to  know  why  a  ceremony 
which  had  already  been  performed  a  year  ago  was  begun 
over  again,  and  protesting  that  it  was  all  a  farce.^ 

§  3.    Attention  and  Association  of  Ideas 

Disorders  of  Attention. — ^Attention  manifests  itself  in 
two  forms:  spontaneous  and  deliberate  or  voluntary.  Spon- 
taneous attention,  the  inferior  and  less  complex  of  the  two 
forms,  consists  "  in  a  direction  of  the  being  toward  the  stimu- 
lus "  or  "in  a  simple  and  spontaneous  fixation  of  phenom- 
ena." Deliberate  attention  directs  the  association  of  ideas 
and  governs  the  course  of  representations,  allowing  each  to 
remain  for -a  greater  or  lesser  length  of  time  in  the  field  of 
consciousness;  in  other  words,  it  brings  about  voluntary  and 
conscious  psychic  activity. 

Complete  paralysis  of  attention  involves  loss  of  spontane- 
ous attention  as  well  as  of  voluntary  attention.  '  It  coexists 
always  with  considerable  clouding  of  consciousness,  there 
being  no  possibility  of  the  production  of  any  state  of  con- 
sciousness without  a  certain  degree  of  at  least  spontaneous 
attention. 

Abnormal  mobility  of  attention  consists  in  paralysis  of 
deliberate  attention,  spontaneous  attention  being  intact  and 
in  most  cases  even  exaggerated.  An  impression  of  any  kind 
suffices  to  distract  the  mind  of  the  subject,  but  no  impression 
can  fix  it.  This  phenomenon  is  well  illustrated  by  the 
following  experiment.  A  manic  patient  was  asked  to  tell 
about  the  death  of  his  mother,  which,  incidentally,  was  the 
cause  of  his  illness.  He  began :  "  The  poor  woman  came 
home  from  her  work  in  the  "vening.  She  was  taken  with  a 
chill.  ..."  One  of  the  assistants  picks  up  a  pencil  from 
the  table  in  front  of  the  patient.     "  Hold  on!  there  is  a  pencil, 

^  Arnaud.  Un  cas  d'illusion  du  deja  vu  ou  de  fausse  memoire.  Ann. 
med.  psych.,  May-June,  1896. 


ATTENTION  AND  ASSOCIATION  49 

a  blue  pencil.  .  .  .  Can  you  draw?  "  Another  assistant 
begins  to  cough.  "  If  you  have  a  cough  you  should  take 
Geraudel's  tablets.  .  .  .  You  know,  spitting  on  the  floor  is 
prohibited.  .  .  .  That's  a  fact.  ..."  The  first  assistant 
unbuttons  his  coat.  "  I  hope  you  are  not  going  to  undress 
here,  that  would  be  improper!  ..."  Noticing  a  small 
rent  in  the  vest  of  the  same  assistant:  "  I  guess  you  have 
no  wife  to  do  your  mending!  ..."  This  example  shows 
how  the  mind,  deprived  of  the  guidance  of  voluntary  atten- 
tion, drifts  at  the  occasion  of  various  external  impressions 
without  ever  becoming  fixed. 

Disorders  of  Association  of  Ideas. — Associations  are 
of  two  kinds:  voluntary  and  automatic.  Voluntary  asso- 
ciations are  under  the  control  of  attention  and  are  effected 
in  a  special  order  which  is  determined  by  a  principal  idea 
termed  the  guiding  idea.  Automatic  associations  are,  on 
the  contrary,  produced  spontaneously  and  without  any 
guiding  idea.  They  constantly  threaten  to  deviate  the  course 
of  voluntary  associations;  one  of  the  principal  functions  of 
deliberate  attention  consists  in  inhibiting  automatic  asso- 
ciations. 

Weakening  of  attention  is  closely  connected  with  sluggish 
formation  of  voluntary  associations.  This  latter  symptom  is 
manifested  clinically  by  slowness  of  apprehension,  and 
experimentally  by  lengthening  of  reaction-time,  that  is,  the 
time  required  for  a  sensation  to  be  transformed  into  a 
voluntary  and  conscious  movement.^ 

Weakening  of  attention  and  sluggishness  of  voluntary 
associations  constitute  the  earliest  and  most  constant  man- 
ifestations of  psychic  paralysis.  Combined  with  insufficiency 
of  perception  and  with  more  or  less  pronounced  disorder  of 
consciousness,  they  bring  about  mental  confusion,  a  syndrome 
which  may  occur  as  an  episode  in  the  course  of  a  great  many 
mental  diseases  and  as  a  permanent  manifestation  of  an 
affection  known  as  primary  mental  confusion, 

1  Pierre  Janet.  Nevroses  et  idees  fixes,  Paris,  F.  Alcan. — Sommer. 
Lehrbuch  der  psychopathologischen  Untersuchungsmethoden,  1899, 


50  SYMPTOMATOLOGY 

The  intensity  of  this  state  may  be  of  three  degrees: 

1st  degree:  diminished  capacity  for  intellectual  exertion, 
rapid  fatigue; 

2d  degree:  intellectual  dullness; 

3d  degree:  complete  suspension  of  all  voluntary  intel- 
lectual activity. 

Weakening  of  attention  and  sluggishness  of  association 
may  exist  alone,  as  in  certain  forms  of  melancholia,  and 
especially  in  stupor,  in  which  they  attain  their  highest  degree. 
They  may  also  be  associated  with  exaggerated  activity  of 
the  mental  automatism,  which  manifests  itself  by  an  abnor- 
mal mobility  of  attention  and  by  a  flow  of  incongruous  ideas 
(flight  of  ideas,  incoherence),  or,  on  the  contrary,  by  the 
appearance  in  the  field  of  consciousness  of  some  particu- 
larly tenacious  and  exclusive  representation  (imperative 
idea,  fixed  idea,  autochthonous  idea). 

Flight  of  Ideas. — Incoherence. — These  two  symptoms 
constitute  two  different  degrees  of  the  same  morbid  process. 

Flight  of  ideas,  almost  always  dependent  upon  an 
abnormal  mobility  of  attention,  consists  of  a  rapid  suc- 
cession of  representations  which  appear  in  the  field  of  con- 
sciousness without  any  order,  at  the  occasion  of  external 
impressions,  superficial  resemblances,  coexistences  in  time 
or  space,  similarities  of  sound,  etc.  One  word  arouses  the 
idea  of  another  of  a  similar  sound  or  having  the  same  ter- 
mination (association  by  assonance).  The  following  ex- 
ample from  a  manic  case  in  which  the  discourse  during  several 
minutes  was  copied  verbatim,  will  show,  better  than  a 
description  could,  the  character  of  this  pathological  phenom- 
enon: 

"  Now  I  want  to  be  a  nice,  accommodating  patient; 
anything  from  sewing  on  a  button,  mending  a  net,  or  scrub- 
bing the  floor,  or  making  a  bed.  I  am  a  jack-of-all-trades 
and  master  of  none!  (Laughs;  notices  nurse.)  But  I 
don't  like  women  to  wait  on  me  when  I  am  in  bed;  I  am 
modest;  this  all  goes  because  I  want  to  get  married  again. 
Oh,  I  am  quite  a  talker;   I  work  for  a  New  York  talking- 


FLIGHT  OF  IDEAS— INCOHERENCE  51 

machine  company.  You  are  a  physician,  but  I  don't  think 
you  are  much  of  a  lawyer,  are  you?  I  demand  that  you  send 
for  a  lawyer!  I  want  him  to  take  evidence.  By  God  in 
Heaven,  my  Saviour,  I  will  make  somebody  sweat!  I 
worked  by  the  sweat  of  my  brow!  (Notices  money  on  the 
table.)  A  quarter;  twenty-five  cents.  In  God  we  trust; 
United  States  of  America;   Army  and  Navy  forever!  " 

Flight  of  ideas  was  formerly  considered,  especially  in 
mania,  the  result  of  excessive  activity  of  normal  intellec- 
tual function;  it  was  believed  that  the  patient,  unable  to 
express  in  words  the  ideas  which  crowd  into  his  consciousness, 
is  compelled  to  leave  out  a  large  number  of  them,  and  that 
these  omissions  cause  the  disconnectedness  of  his  discourse. 
In  reality  this  exaggerated  activity  affects  only  the 
automatic  intellectual  functions  and  is  always  associated 
with  a  weakening  of  the  higher  psychic  functions.  The 
essential  cause  of  the  phenomenon  is  to  be  looked  for  in  a 
weakness  of  attention:  representation  A  cannot  fix  itself  in 
consciousness  and  is  immediately  replaced  by  representation 
B,  and  so  on. 

While  in  flight  of  ideas  the  representations  are  still 
associated  by  their  relations,  which  though  superficial  are 
yet  real,  in  incoherence  they  follow  each  other  without  any 
apparent  connection.  The  following  is  a  specimen  of 
incoherent  speech  obtained  from  a  case  of  dementia  prsecox: 
"  What  liver  and  bacon  is  I  don't  know.  You  are  a  spare; 
the  spare;  that's  all.  It  is  Aunt  Mary.  Is  it  Aunt  Mary? 
Would  you  look  at  the  thing?  What  would  you  think? 
Cold  cream.  That's  all.  Well,  I  thought  a  comediata. 
Don't  worry  about  a  comediata.  You  write.  He  is  writing. 
Shouldn't  write.  That's  all.  I'll  bet  you  have  a  lump 
on  your  back.  That's  all.  I  looked  out  the  window  and 
I  didn't  know  what  underground  announcements  are. 
My  husband  had  to  take  dogs  for  a  fit  of  sickness." 

These  few  lines  suffice  to  show  the  profound  degree  of 
psychic  disaggregation  which  is  manifested  by  this  phe- 
nomenon. 


52  SYMPTOMATOLOGY 

It  is  not  uncommon  for  the  two  symptoms,  flight  of 
ideas  and  incoherence,  to  appear  in  succession,  or  even  to- 
gether, in  the  same  subject,  notably  in  cases  of  mania,  in 
acute  mental  confusion,  also,  though  less  often,  in  dementia 
praecox. 

Imperative  Idea — Fixed  Idea — Autochthonous  Idea.^ — 
We  have  stated  above  that  mental  automatism  may  mani- 
fest itself  by  the  appearance  of  an  idea  that  is  particularly 
tenacious  and  exclusive,  occupying  by  itself  the  field  of 
consciousness,  from  which  nothing  can  dislodge  it.^ 

The  three  forms  in  which  this  phenomenon  may  appear 
have  been  well  defined  by  Wernicke.^ 

An  imperative  idea  imposes  itself  upon  the  patient's 
consciousness  against  his  will;  he  recognizes  its  pathological 
character  and  seeks  to  rid  himself  of  it.  It  is  a  parasitic 
idea,  recognized  as  such  by  the  patient. 

A  mother  is  haunted  by  the  idea  of  killing  her  child 
whom  she  loves  dearly.  As  she  herself  states,  she  can  no 
longer  think  of  anything  else;  but  she  recognizes  it  as  a 
morbid  phenomenon  and  begs  to  be  relieved  of  it :  this  is  an 
imperative  idea. 

A  fixed  idea,  on  the  contrary,  harmonizes  with  the 
other  representations.  Therefore  it  is  never  considered 
by  the  subject  as  foreign  to  the  mind  or  as  a  pathological 
phenomenon. 

A  mother  who  has  lost  her  child  is  convinced  that  if 
she  had  given  it  a  certain  kind  of  medicine  the  child  would 
not  have  died.  This  idea  does  not  leave  her,  appears  to  her 
perfectly  legitimate  and  natural:   this  is  a  fixed  idea. 

Fixed  ideas  form  the  basis  of  certain  delusional  states, 
notably  paranoia. 

Fixed  ideas  are  not  found  exclusively  in  cases  of  mental 

^  Milne  Bramwell.  On  Imperative  Ideas.  Brain,  1895. — Keraval. 
L'ideefixe.     Arch,  de  Neurol,  1899,  Nos.  43  and  44. 

2  This  form  of  mental  automatism  may  be  termed  monoideal  autom- 
atism. 

3  Loc.  cit.,  p.  108. 


AUTOCHTHONOUS  IDEAS  53 

alienation;  they  are  encountered  in  the  normal  state  as 
certain  tendencies  that  may  be  in  themselves  perfectly 
legitimate.     Such  are  desire  for  vengeance,  ambition,  etc. 

Autochthonous  ideas,  like  imperative  ideas,  develop 
alongside  of  normal  associations.  The  only  difference  is  in 
the  patient's  interpretation  of  them;  while  an  imperative 
idea  is  recognized  by  him  as  pathological,  an  autochthonous 
idea  is  attributed  to  some  malevolent  influence,  most  fre- 
quently to  some  strange  personality.  If  he  complains,  it  is 
to  the  police  officer  and  not  to  the  physician.  A  mother 
believes  that  her  neighbor  forces  upon  her  the  idea  of  killing 
her  child:  this  is  an  autochthonous  idea. 

Closely  related  to  imperative  ideas,  autochthonous  ideas 
present  a  similar  analogy  to  hallucinations;  hke  hallucina- 
tions, they  are  thought  to  be  caused  by  automatic  activ- 
ity of  a  cortical  center.  But,  instead  of  playing  upon  a 
psychosensory  center,  the  morbid  irritation  occurs  in  a 
psychic  center.  Baillarger  designated  autochthonous  ideas 
by  the  term  psychic  hallucinations}  This  term  has  lately 
fallen  into  disuse,  perhaps  undeservedly. 

Nothing  proves  more  conclusively  the  kinship  of  the 
two  classes  of  symptoms  than  the  frequent  transforma- 
tion of  autochthonous  ideas  into  auditory,  motor,  and 
occasionally  even  visual,  verbal  hallucinations.  The  analogy 
between  autochthonous  ideas  and  verbal  motor  halluci- 
nations led  Seglas  ^  to  consider  the  two  phenomena  as 
identical  in  their  nature,  the  first  being  but  a  rudimentary 
form  of  the  second.  This  opinion  will  appear  somewhat 
exclusive  if  we  take  into  consideration  the  fact  that  autoch- 
thonous ideas  may  engender  auditory  hallucinations  ^ 
just  as  readily  as  motor  hallucinations,  and  that  in  many, 
cases  they  are  not  accompanied  by  even  the  slightest  sensa- 
tion of  movement. 

^  Marandon  de  Montyel.  Des  hallucinations  psTjchiques.  Gaz. 
hebd.  de  Med.  et  de  Chirurgie,  March,  1900. 

2  Legons  cliniques  sur  les  maladies  mentales  et  nerveuses.  ■ 
2  Wernicke.    Loc.  cit. 


54  SYMPTOMATOLOGY 

Psychic  hallucinations  generally  indicate  advanced  dis- 
aggregation of  the  personality  and  therefore  point  to  a  grave 
prognosis. 

§  4.      DiSOEDERS   OF  JUDGMENT 

Judgment  is  the  act  by  which  the  mind  determines  the 
relationship  between  two  or  more  representations. 

When  the  relationship  is  imaginary  the  judgment  arrives 
at  a  false  conclusion.  This  becomes  a  delusion  when  it  is  in 
obvious  conflict  with  evidence. 

False  ideas  which  patients  often  entertain  .  concerning 
their  own  condition,  believing  their  health  to  be  perfect 
when  in  reality  it  is  seriously  affected,  are  to  be  attributed 
to  impaired  judgment  [lack  of  insight].  This  lack  of  appre- 
ciation of  their  own  condition  is  not  always  absolute,  and 
though  in  general  it  may  be  truly  said  that  mental  disease 
often  does  not  recognize  itself,  it  must,  however,  be  acknowl- 
edged that  sometimes,  chiefly  at  the  onset  of  the  psychoses, 
the  patients  are  conscious  of  pathological  changes  taking 
place  in  them.^ 

Some  apply  to  the  physician  of  their  own  accord,  or 
even  request  to  be  committed.  A  sufferer  from  a  recurrent 
psychosis,  treated  several  times  at  the  Clermont  Hospital, 
had  at  the  beginning  of  his  attacks  such  perfect  realiza- 
tion of  his  state  that  he  would  request  by  telegram  to  have 
attendants  sent  after  him. 

General  Properties  of  Delusions. — The  sum  of  a  patient's 
delusions  constitutes  a  delusional  system. 

Such  a  system  may  consist  of  purely  imaginary  ideas, 
•or  of  ideas  based  upon  facts  improperly  interpreted. 

In  the  latter  case  we  have  false  interpretations.  When 
false  interpretations  involve  occurrences  of  the  past  they 
are  termed  retrospective  falsifications. 

1  Pick.  Ueber  Krankheitsbewusstsein  in  psrjchischen  Krankheiten. 
Arch.  f.  Psychiat.,  Vol.  XIII. — Heilbronner.  Ueber  Krankheitseinsicht. 
Allg.  Zeitsch.  f.  Psychiat.,  Vol.  LIV.,  No.  4. 


DISORDERS  OF  JUDGMENT  55 

Sometimes  a  delusional  state  follows  a  dream,  is  con- 
founded with  it,  and  presents  all  the  characteristics  of 
it  (dream  delirium);  this  occurs  in  many  infectious  and 
toxic  psychoses. 

Almost  always  delusions  are  multiple.  Even  in  those 
cases  which  are  sometimes  designated  by  the  term  mono- 
mania, the  primary  morbid  idea  entails  a  certain  number  of 
secondary  morbid  ideas  which  result  from  it.  In  some  cases 
different  delusional  conceptions  coexist  without  there  being 
any  connection  between  them,  in  others  they  are  grouped 
so  as  to  form  a  more  or  less  logical  whole  possessing  greater 
or  less  plausibility.  In  the  first  instance  the  delusions  are 
said  to  be  incoherent,  in  the  second  systematized. 

Whether  systematized  or  not,  delusions,  like  hallucina- 
tions, generally  harmonize  with  the  emotional  tone.  This 
harmony  disappears  when  the  pathological  process  becomes 
abated  in  intensity,  as  the  patient  either  enters  upon  his 
convalescence  or  lapses  into  mental  deterioration.  In 
dements  the  delusions  often  affect  neither  the  emotions  nor 
the  reactions.  A  patient  may  claim  that  he  is  an  emperor 
and  yet  consent  to  sweep  the  hall;  or  one  may  believe  him- 
self to  have  lost  his  stomach  and  still  eat  with  a  hearty 
appetite. 

Three  great  categories  of  delusions  are  usually  distin- 
guished : 

Melancholy  ideas; 

Ideas  of  persecution; 

Ideas  of  grandeur. 

We  shall  limit  ourselves  here  to  a  brief  sketch  of  these, 
reserving  the  details  for  consideration  in  connection  with 
the  affections  in  which  the  delusions  occur. 

Melancholy  Ideas. — Very  common  at  the  beginning 
of  psychoses,  melancholy  ideas  may  persist  through  the 
entire  duration  of  the  disease,  as  in  involutional  melanchoHa. 

The  principal  varieties  are : 

(A)  Ideas  of  humiHty  and  of  culpability.  The  latter 
are  also  called  ideas  of  self -accusation; 


56  SYMPTOMATOLOGY 

(B)  Ideas  of  ruin ; 

(C)  Hypochondriacal  ideas; 

(D)  Ideas  of  negation. 

(A)  Ideas  of  Humility  and  of  Culpahility. — The  patient 
considers  himself  a  being  good  for  nothing,  wretched,  un- 
deserving of  the  attention  bestowed  upon  him,  and  accuses 
himself  of  imaginary  faults  or  crimes.  Often  he  will  seek 
out  from  his  past  life  some  insignificant  act  to  which  he 
will  attribute  extreme  gravity:  he  stole  some  apples  when 
he  was  a  boy,  or  he  forgot  to  make  the  sign  of  the  cross 
once  upon  entering  a  church.  The  idea  of  the  crime  com- 
mitted entails  also  ideas  of  merited  punishment:  he  expects 
every  instant  to  be  arrested,  put  to  death,  cut  to  pieces, 
thrown  into  hell,  etc. 

(B)  Ideas  of  Ruin. — These  are  frequent  in  senile  de- 
ments; the  patient  believes  himself  to  be  without  any 
means,  bereft  of  everything;  his  clothes  will  be  sold;  some 
day  he  will  be  found  dead  of  starvation  on  a  public  road. 

(C)  Hypochondriacal  Ideas. — These  concern  the  subject 
himself,  involving  either  the  physical  sphere — the  stomach  is 
obstructed,  the  spinal  marrow  is  softened,  the  entire  organ- 
ism is  affected  by  an  incurable  disease — or  the  psychic 
sphere,  constituting  psychic  hypochondriasis:  the  mind 
is  paralyzed,  the  intelligence  is  destroyed,  the  will  power 
is  annihilated. 

Hypochondriacal  ideas  are  sometimes  dependent  upon 
an  actual  diseased  condition  which,  however,  is  falsely  inter- 
preted by  the  patient  (Hypochondria  cum  materia).^ 

(D)  Ideas  of  Negation.^ — In  some  cases  these  concern 
the  subject  himself,  and  are  then  nothing  but  hypochon- 

1  Pick.  Zur  Lehre  von  der  Hypochondrie.  Allg.  Zeitschei*.  f .  Psychiat, 
1903,  Nos.  1-2. 

^  Seglas.  Legons  cliniques,  p.  276. — Cotard.  Du  delire  des  nega- 
tions. Arch,  de  neurol.,  1882. — Arnaud.  Sur  le  delire  des  negations. 
Ann.  med.  psychol.,  Nov.-Dec.  1892. — S6glas.  Le  delire  des  nega- 
tions. Encycl.  des  Aide-mem. — Trenel.  Notes  sur  les  idees  de  nega- 
tion. Arch,  de  neurol.,  March,  1899. — Castin.  Un  cas  de  delire  hypo- 
chondriaque  a  forme  evolutive.     Ann.  m6d.  psych.,  June,  1900. 


DISORDERS  OF  JUDGMENT  67 

driacal  ideas  pushed  to  an  extreme:  the  brain,  the  heart, 
etc.,  are  destroyed,  the  bones  are  replaced  by  air,  the  body 
is  nothing  but  a  shadow  without  a  real  existence.  In  other 
cases  they  are  referred  to  the  external  world:  the  sun  is 
dead,  the  earth  is  nothing  but  a  shadow,  the  universe  itself 
exists  no  more  (metaphysical  ideas  of  negation). 

By  a  singular  process,  apparently  paradoxical,  hypo- 
chondriacal ideas  and  those  of  negation  give  rise  to  ideas 
of  immortality  and  of  immensity.  The  patient,  feeling 
himself,  on  account  of  the  destruction  of  his  organs,  placed 
beyond  the  laws  of  nature,  concludes  that  he  cannot  die 
and  that  he  is  condemned  to  suffer  eternally;  or,  dismayed 
by  the  form  and  monstrous  dimensions  of  his  body,  he 
imagines  himself  obscuring  the  atmosphere,  filling  the 
world,  etc. 

The  general  features  of  melancholy  delusional  states 
are  the  expression  of  psychic  inhibition  and  of  the  painful 
emotional  tone  which  constitute  the  basis  of  the  melancholy 
state. 

The  following  is  a  summary  of  the  chief  characteristics 
of  these  states,  according  to  the  admirable  study  of  Seglas: 

(a)  Melancholy  delusions  are  monotonous;  the  same 
delusions  are  constantly  repeated,  the  inhibition  allowing 
but  little  formation  and  appearance  of  new  ideas. 

(6)  These  states  are  humble  and  passive.  The  patient 
accuses  no  one  but  himself,  and  submits  without  resistance 
to  the  ill-treatment  which  he  believes  himself  to  have 
deserved. 

(c)  As  to  localization  in  time,  the  delusions  are  referred 
to  the  past  and  to  the  future:  the  patient  finds  in  the  past 
the  imaginary  sins  which  he  has  committed,  and  foresees  in 
the  future  the  chastisements  which  are  to  be  inflicted  upon 
him.  In  this  respect  melancholy  delusional  states  are  in 
contrast  with  persecutory  delusional  states.  The  perse- 
cuted patient  localizes  his  delusions  chiefly  in  the  present. 
The  persecutions  of  which  he  complains  are  actual. 

(f/)  From  the  standpoint  of  its  development  the  melan- 


58  DISORDERS  OF  JUDG^IEXT 

Some  patients  do  not  know  their  persecutors.  Others 
accuse  particular  persons  or  societies  (Jesuits,  Free- 
masons). Still  others  bear  their  hatred  towards  some 
certain  individual  who  is,  in  their  eyes,  the  instigator  of  all 
the  injurious  procedures  of  which  they  are  the  victims, 
"  the  great  master  of  the  persecutions,"  as  one  such  patient 
once  said. 

Of  all  delusions  those  of  persecution  are  the  most  irreduc- 
ible and  are  held  by  the  patients  with  the  firmest  con- 
viction. Almost  always  the  patients  resent  to  have  them 
disputed.  In  themselves  these  delusions  do  not  have  an 
invariable  influence  upon  the  prognosis,  excepting  that,  in  a 
verj'  general  waj',  they  are  of  more  serious  import  than  melan- 
choly ideas. 

Of  all  delusions  these  also  present  the  greatest  tendency 
to  systematization  and  to  progressive  evolution.  A  perfect 
persecutor}^  delusional  system  should  comprise: 

(a)  A  precise  idea  of  the  nature  of  the  persecutions; 

(6)  An  exact  knowledge  of  the  persecutors,  of  their 
aim,  and  of  the  means  employed  bj^  them; 

(c)  A  plan  of  defense  in  harmony  with  the  natm'e  of 
the  delusions. 

In  the  examination  of  cases  with  persecutory  ideas 
one  should  always  attempt  to  determine  these  points, 
on  account  of  their  great  practical  importance. 

Ideas  of  Grandeur. — Ideas  of  grandeur  appear  chiefly 
in  demented  states  and  are  often  of  a  particular^  absurd 
nature,  bearing  the  stamp  of  mental  deterioration.  The 
patients  are  immensely  rich,  all-powerful;  they  are  popes, 
emperors,  creators  of  the  universe.  Generalty  thej^  naively 
claim  these  pompous  titles  without  being  at  all  concerned  by 
the  flagrant  contradiction  existing  between  theu'  actual  state 
and  their  ostensible  almightmess.  A  general  paralytic 
was  once  asked:  "  If  you  are  God,  how,  then,  does  it  happen 
that  3^ou  are  locked  up?  "  "  Because  the  doctor  refuses  to 
let  me  go,"  he  replied  simply.  It  is  not  rare  to  see  a  pseudo- 
pope  obey  without  a  murmur  the  orders  of  hospital  attend- 


SYMPTOMATOLOGY  59 

choly  delusional  state  is  centrifugal.  The  trouble  begins 
with  the  patient  and  extends  gradually  to  his  friends,  his 
country,  and  the  entire  universe,  who  suffer  through  his 
faults. 

(e)  The  melancholy  delusional  state  is  secondary,  that 
is  to  say,  it  is  the  consequence  of  sadness  and  of  psychic 
pain.  It  shares  this  characteristic  with  most  of  the  other 
delusional  states  which  are  generally  but  the  expression  of 
the  emotional  tone  of  the  subject.^ 

Melancholy  delusions  may  have  two  grave  consequences 
which  we  shall  many  times  have  occasion  to  emphasize: 
suicidal  tendency  and  refusal  of  food. 

Ideas  of  Persecution. — Like  melancholy  ideas,  ideas 
of  persecution  are  of  a  painful  character.  But  while  the 
melancholiac  considers  himself  a  culpable  victim  and  submits 
beforehand  to  the  chastisements  which  he  believes  he  has 
merited,  the  subject  of  persecution  is  convinced  of  his  inno- 
cence and  protests  and  defends  himself. 

Ideas  of  persecution  may  be  divided  into  two  groups, 
according  to  whether  or  not  they  are  accompanied  by  hallu- 
cinations. 

Those  of  the  first  group  are  associated  with  hallucinations 
generally  of  an  unpleasant  character,  among  which  auditory 
verbal  hallucinations  and  hallucinations  of  general  sensibility 
are  most  prominent.  After  a  certain  time  the  phenomena 
of  physic  disaggregation  supervene:  motor  hallucinations, 
autochthonous  ideas,  reduplication  of  the  personality,  etc. 

In  the  second  group  are  ideas  of  persecution  peculiarly 
associated  with  false  interpretations;  any  chance  occurrence 
is  ascribed  by  the  patient  to  malevolence;  he  sees  in  every- 
thing evidences  of  hostility  against  him,  and  attributes  to 
the  most  ordinary  and  unimportant  facts  and  actions  a  sig- 
nificance which  is  as  grave  as  it  is  fanciful.  This  form  of 
ideas  of  persecution  is  frequent  at  the  onset  of  certain 
psychoses;  it  also  constitutes  the  basis  of  an  affection  known 
as  paranoia  or  reasoning  insanity. 

1  Seglas.     Legons  cliniques. 


60  SYMPTOMATOLOGY 

ants  and  assist  with  the  best  possible  grace  in  the  most  menial 
labor. 

Often  the  patient's  attire  is  in  harmony  with  the  title: 
uniforms  of  the  oddest  fancy,  multicolored  tinsels,  numerous 
decorations,  etc. 

When  the  mental  deterioration  is  less  pronounced,  as, 
for  instance,  in  certain  cases  of  dementia  praecox,  the  subject 
shows  more  logic  in  his  conduct.  He  assumes  an  air  of 
dignity,  avoids  all  association  with  the  other  patients,  and 
declines  with  a  contemptuous  smile  all  suggestion  of  em- 
ployment. 

Ideas  of  grandeur  are  also  met  with  in  certain  acute 
psychoses,  as  in  mania,  for  instance,  and  in  certain  forms 
of  systematized  delusional  states  without  mental  deteriora- 
tion (Paranoia  originaire  of  Sander), 


CHAPTER    IV 

SYMPTOMATOLOGY  {Concluded) 

AFFECTIVITY— REACTIONS— C(ENESTHESIA— NOTION    OF 
PERSONALITY 

§  1.    Disorders  of  Affectivity 

Pathological  modifications  of  affectivity  are  encountered 
in  the  course  of  all  psychoses.  They  always  appear  early, 
and  often  before  any  of  the  other  symptoms. 

The  principal  ones  are: 

(a)  Diminution  of  affectivity:   morbid  indifference; 

(6)  Exaggeration  of  affectivity; 

(c)  Morbid  depression. 

(d)  Morbid  anger; 

(e)  Morbid  joy. 

Diminution  of  Affectivity. — In  its  most  pronounced 
degree  indifference  involves  all  the  emotions,  as  in  extreme 
states  of  dementia  (general  paralysis  and  senile  dementia 
in  their  terminal  stages),  in  which  it  is  associated  with 
general  mental  deterioration.  In  less  severe  forms  indif- 
ference is  manifested  by  disappearance  of  the  most  ele- 
vated and  the  most  complex  sentiments,  with  conservation 
and  often  exaggeration  of  the  sentiments  of  an  inferior 
order.  The  altruistic  tendencies  are  the  first  to  become 
effaced,  while  the  egoistic  sentiments  persist.  Only  the  satis- 
faction of  their  material  wants  still  concerns  the  patients  and 
governs  their  conduct.  Many  take  no  interest  during  the 
visits  of  relatives  in  anything  excepting  the  eatables  brought 
to  them;    they  eat  as  much  as  they  can,  fill  their  pockets 

61 


62  SYMPTOMATOLOGY 

with  the  rest,  and  leave  without  taking  the  trouble  to 
express  their  thanks  or  even  to  bid  their  visitors  good-by. 

Morbid  indifference  may  be  conscious  or  unconscious. 
In  the  first  case  it  is  realized  by  the  subject  as  a  painful 
phenomenon.  The  patients  often  say:  "  I  have  lost  all 
feeling,  nothing  excites  me,  nothing  pleases  me,  nothing 
makes  me  sad."  Some  complain  of  being  unable  to  suffer. 
This  state,  which  may  be  called  painful  psychic  ancesthesia, 
is  frequent  at  the  beginning  of  psychoses  and  sometimes 
persists  through  the  entire  duration  of  the  affection  (involu- 
tional melancholia,  depressed  periods  of  recurrent  psychoses). 

In  the  second  case,  which  is  more  frequent,  the  diminution 
of  affectivity  is  not  noticed  by  the  patient.  Such  is  always 
the  case  in  states  of  dementia. 

The  changes  of  other  mental  faculties,  such  as  memory 
and  general  intelligence,  are  not  necessarily  proportionate 
to  those  of  affectivity.  Notably  in  dementia  praecox  it  is 
not  rare  to  find  fairly  good  memory  and  relatively  lucid 
intelligence  coexisting  with  complete  indifference. 

Exaggeration  of  Affectivity. — Often  combined  with  in- 
difference, as  described  above,  exaggeration  of  affectivity 
is  encountered  in  most  mental  affections,  congenital  and 
acquired.  It  constitutes  the  basis  of  irritable  and  changeable 
moods  and  of  the  extreme  irascibility  so  often  seen  among 
the  psychotic  and  among  neuropaths  in  general. 

In  psychoses  it  is  an  early  symptom,  appearing  at  times 
long  before  the  other  phemonema.  An  individual  previously 
calm,  gentle,  kind,  becomes  disagreeable,  ill-natured,  violent. 
"  He  is  completely  changed,"  is  a  remark  often  made  by  the 
relatives. 

Irritability  is  almost  always  associated  with  variability 
of  moods. 

Disorders  of  affectivity  characterize  a  large  and  im- 
portant group  of  cases  included  under  the  somewhat  vague 
designation  of  constitutional  psychopathic  states.  In  these 
subjects  the  emotions  are  entirely  out  of  proportion  with 
their  causes.     The  death  of  an  animal  plunges  them  into 


DISORDERS  OF  AFFECTIVITY  63 

unlimited  despair,  the  sight  of  blood  brings  on  syncope, 
the  most  simple  affairs  preoccupy  their  minds  so  as  to  make 
them  lose  sleep.  Sensitive  in  the  highest  degree,  they 
see  in  everything  malevolent  intentions,  disguised  reproaches. 
But  their  sentiments,  though  very  intense,  do  not  last  long; 
sorrows,  enthusiasms,  resentments,  are  with  them  but  a 
short  blaze. 

Morbid  Depression. — Depression  presents  itself  in  patho- 
logical states,  as  it  does  in  the  normal  state,  in  two  forms: 
active  and  passive.  This  distinction  is  founded  upon  the 
presence  or  absence,  or  rather  upon  the  intensity,  of  psychic 
pain.  While  in  active  depression  psychic  pain  is  very  promi- 
nent, in  passive  depression  it  is  dull,  vague,  scarcely  appre- 
ciable. Indeed,  as  Dumas  says,  "  the  element  of  pain  is 
not  absent  in  passive  melancholia;  but  is  it  not  an  acute 
and  distinct  psychic  pain.     It  is  but  vaguely  perceived."  ^ 

Passive  Depression. — The  fundamental  features  of  pas- 
sive depression  are  lassitude,  discouragement,  resignation. 
It  is  always  associated  with  a  marked  degree  of  psychic 
inhibition,  aboulia,  and  moral  ancesthesia,  and  may  be  com- 
plicated by  delusions  and  hallucinations.  It  is  accom- 
panied by  organic  changes  which  have  been  extensively 
studied  by  physiologists  (Darwin,  Claude  Bernard,  Lange), 
and  to  which  Dumas  has  devoted  one  of  the  most  interesting 
chapters  in  his  book,  "  La  tristesse  et  la  joie." 

Depression  is  always  associated  with  a  state  of  periph- 
eral and  probably  cerebral  vaso-constriction,  in  which 
Lange  believed  he  had  found  the  immediate  cause  of  this 
emotion.  This  vaso-constriction  is  apparent  in  the  pallor 
of  the  skin,  coldness  of  the  extremities,  and  absence  of  the 
peripheral  pulse,  which  are  constant  features  of  the  depres- 
sion of  melancholia.  The  opinion  of  Lange  is,  however, 
too  exclusive.  "  This  vaso-constriction,  which  in  the 
peripheral  organs  results  in  coldness  and  pallor  of  the  tissues, 
brings  about  in  the  brain  a  condition  of  anaemia,  undoubtedly 
contributing  to  the  maintenance  of  the  mental  and  motor 
1  La  tristesse  et  la  joie,  p.  29.     Paris,  F.  Alcan. 


64  SYMPTOMATOLOGY 

inertia;  but  it  cannot  be  asserted  positively  that  it  is  the 
only  cause  of  these  phenomena.  Morselli  and  Bordoni- 
■  Uffreduzzi  have  shown  long  since,  in  fact,  that  the  phe- 
nomena of  depressed  intellectual  activity  may  appear 
before  the  cerebral  circulatory  changes;  this  leads  to  the 
conclusion  that  depression  begins  with  being  the  cause  of 
the  circulatory  changes  before  becoming  subject  to  their 
influence."  ^ 

In  the  very  rare  cases  in  which,  in  spite  of  the  peripheral 
vaso-constriction,  the  cardiac  impulse  retains  its  force,  the 
blood  pressure,  according  to  the  laws  formulated  by  Marey, 
rises;  this  condition  constitutes  the  first  type  of  depression, 
depression  with  hypertension. 

But  almost  always  the  heart  participates  in  the  general 
atony  characterizing  depression,  so  that  the  blood  pressure 
falls  in  spite  of  the  peripheral  vaso-constriction:  this  con- 
stitutes the  second  type  of  depression,  depression  with 
hypotension  (Dumas). 

The  respiratory  disorders  are  no  less  constant  than  the 
circulatory  ones.  The  respirations  are  shallow,  irregular, 
interrupted  by  deep  sighing.  The  quantity  of  carbon  diox- 
ide excreted  tends  to  diminish. 

The  general  nutrition  is  impaired;  this  results  in  loss 
of  flesh,  which  is  but  slight  if  the  depression  lasts  no  longer 
than  a  few  days,  and  which  persists  as  long  as  the  affective 
phenomenon  itself.  The  weight  does  not  return  to  the 
normal  until  the  depression  disappears,  i.e.,  until  the  patient 
either  recovers  or  becomes  demented. 

The  appetite  is  diminished,  the  tongue  is  coated,  the 
breath  is  offensive.  The  process  of  digestion  is  accom- 
panied by  discomfort  and  often  by  pain  in  the  epigas- 
trium.    Finally,  there  is  almost  always  constipation. 

The  sluggish  metabolism  shown  by  the  diminished 
elimination  of  carbon  dioxide  is  also  apparent  from  the 
quantitative  and  qualitative  changes  in  the  urinary  ex- 
cretion. The  quantity  of  urine  voided  in  twenty-four 
^  Dumas.    Loc.  cit.,  p.  239. 


DISORDERS  OF  AFFECTIVITY  65 

hours  is  diminished.  The  quantity  of  urea,  as  well  as 
that  of  phosphoric  acid,  is  also  diminished.  (Observations 
of  Dumas  and  Serveaux.) 

The  toxicity  of  the  urine  in  depression  is  undoubtedly 
of  interest,  but  the  results  so  far  obtained  are  somewhat 
conflicting.  According  to  some  authors  it  is  increased, 
according  to  others,  diminished.  This  subject,  still  in 
a  state  of  confusion,  should  be  excluded  from  the  domain 
of  practical  psychiatry. 

Active  Depression. — The  special  feature  of  active  de- 
pression is  psychic  pain,  which  is  distinct  and  suffi- 
ciently intense  to  render  the  subject  subjectively  conscious 
of  it.  The  appearance  of  this  new  phenomenon  modifies  to 
a  certain  extent  the  fundamental  symptoms  which  have 
been  described  in  connection  with  passive  depression. 

Like  physical  pain,  psychic  pain  tends  to  limit  the 
field  of  consciousness,  to  exclude  other  mental  manifesta- 
tions, and  to  become  what  Schiile  has  designated  by  the 
term  pain-idea.  In  certain  cases  the  disturbance  of  con- 
sciousness which  it  causes  results  in  marked  disorientation 
and  confusion.  These  phenomena,  caused  by  the  pain, 
become  less  marked  as  the  pain  becomes  abated  in  intensity 
and  disappear  as  the  paroxysm  passes  off. 

When  psychic  pain  attains  a  certain  intensity  it  results 
in  anxiety.  This  phenomenon  consists  chiefly  in  a  feeling 
of  oppression  or  constriction,  most  frequently  localized  in 
the  precordial  region,  occasionally  in  the  epigastrium  or  in 
the  throat,  and  more  rarely  in  the  head.  This  peculiar  feel- 
ing is  always  accompanied  by  certain  somatic  phenomena, 
the  most  important  of  which  are  pallor  of  the  skin,  sometimes 
cyanosis,  panting  respiration,  general  tremor,  irregular  and 
accelerated  pulse,  and  dilatation  of  the  pupils. 

Anxiety  is  frequently  seen  in  the  melancholias.  It 
also  occurs  in  cases  of  obsession.  It  may  appear  without 
cause  in  constitutional  psychopaths  (the  paroxysmal  anxiety 
of  Brissaud) . 

From  the   standpoint   of  the   reactions,   psychic   pain, 


66  SYMPTOMATOLOGY 

like  physical  pain,  may  manifest  itself  either  by  a  sort  of 
psychomotor  paralysis — so  that  the  patient  remains  im- 
movable, with  a  haggard  expression,  silenced,  so  to  speak, 
by  the  anxiety — or  by  various  phenomena  of  agitation. 

In  the  latter  case,  the  more  frequent,  the  pain,  an  active 
phenomenon,  brings  about  a  reaction  which  to  a  certain 
extent  overcomes  the  fundamental  psychic  inhibition  and 
manifests  itself  by  two  sjmiptoms  which  are  frequently 
seen  together,  motor  agitation  and  delusions. 

Acting  as  a  stimulus,  psychic  pain  overcomes  the  motor 
inertia  of  melanchoha  and  gives  rise  to  melancholy  agitation, 
which  is  characterized  by  movements  that  are,  in  the 
normal  state,  the  expression  of  violent  despair.  The  patient 
wrings  his  hands,  strikes  his  head  against  the  wall,  etc. 
The  agitation  of  anxiety  is  essentially  an  expression  of 
opposition,  of  resistance.  The  reactions  are  either  auto- 
matic or  governed  by  delusions:  movements  of  flight, 
refusal  of  food,  attempts  of  suicide,  etc. 

Suicide  is  one  of  the  most  formidable  consequences  of 
psychic  pain.  Though  most  melanchoHacs  have  a  desire 
to  die,  the  aboulia  wliich  characterizes  the  state  of  depres- 
sion very  seldom  permits  them  to  carry  out  their  desire. 
On  recovf^ring  part  of  their  energy  they  are  apt  to  make 
suicidal  attempts. 

Delusions  are  a  frequent  but  not  constant  manifesta- 
tion of  psychic  pain.  They  are  absent  in  certain  cases 
of  melanchoha  in  spite  of  the  existence  of  even  very  painful 
depression. 

What  is  the  mechanism  of  the  production  of  delusions 
in  melancholia?  The  most  widely  accepted  opinion  is 
that  of  Griesinger;!  "The  patient  feels  that  he  is  a  prey 
to  sadness;  but  he  is  usually  not  sad  except  under  the 
influence  of  depressing  causes:  moreover,  according  to  the 
general  law  of  cause  and  effect,  this  sadness  must  have  a 
ground,  a  cause — and  before  he  asks  himself  this  question, 
he  already  has  an  answer:    all  kinds  of  mournful  thoughts 

1  Griesinger.     Pathologie  und  Therapie  der  psychischen  Krankheiten. 


DISORDERS  OF  AFFECTIVITY  67 

occur  to  him  as  explanations ;  dark  presentiments,  apprehen- 
sions, over  which  he  broods  and  ponders  until  some  of  these 
ideas  become  so  dominating  and  so  persistent  as  to  fix 
themselves  in  his  mind,  at  least  for  some  time.  For  this 
reason  these  delusions  have  the  character  of  attempts  on  the 
part  of  the  patient  to  explain  to  himself  his  own  state." 

Though  of  great  interest,  this  ingenious  theory  is  per- 
haps somewhat  too  exclusive.  Kraepelin  has  noted,  in 
fact,  that  the  delusions  occurring  in  states  of  depression 
do  not  always  present  the  character  of  explanations  sought 
by  the  patient.  Many  melancholiacs  instead  of  accepting 
the  delusions,  on  the  contrary  reject  them,  at  least  in  the  be- 
ginning. Again,  the  appearance  of  a  delusion  does  not 
bring  with  it  the  relative  calm  which  would  be  expected 
if  it  really  constituted  the  explanations  sought  by  the 
patient.  It  seems,  then,  that  this  interpretation,  ingenious 
though  it  is,  is  rather  superficial.  The  view  of  Dumas 
appears  to  be  nearer  the  truth.  Psychic  pain  provokes 
delusions  because  it  acts  as  a  stimulus,  struggling  against 
the  lassitude,  and  finally  conquering  it.  Thus  there  is  no 
logical  relationship  between  psychic  pain  and  delusions, 
but  rather  a  dynamic  one. 

Morbid  Anger. — Pain,  associated  with  a  representation 
of  its  cause,  and  sufficiently  intense  to  overcome  the  psychic 
paralysis  which  is  an  essential  accompaniment  of  depres- 
sion, results  in  anger. 

The  violent  and  disordered  reactions  displayed  in  anger 
have  a  purely  automatic  origin,  and  are  often  associated 
with  disturbance  of  consciousness  and  of  perception  which 
finds  various  expressions  in  popular  language :  a  man  who  is 
a  victim  of  violent  anger  is  often  said  to  be  "  beside  himself," 
he  "  forgets  himself." 

Like  all  emotions,  anger  is  accompanied  by  somatic 
changes.  The  principal  ones  are :  increase  of  cardiac  a^^tion 
and  elevation  of  arterial  tension;  peripheral  vaso-dilatation, 
chiefly  noticeable  in  the  face,  which  assumes  a  congested 
appearance;    jerky  and  convulsive   respiratory  movements: 


68  SYMPTOMATOLOGY 

increase  of  most  of  the  secretions;  abundant  salivation 
(foaming),  more  or  less  jaundice,  diarrhoea,  polyuria;  some- 
times suspension  of  the  milk  secretion;  arrest  of  the 
menstrual  flow;  more  or  less  marked  cutaneous  anaesthesia; 
general  tremor. 

Anger  may  be  met  with  in  all  psychoses,  excepting 
perhaps  involutional  melancholia.  It  somelimes  reaches 
the  intensity  of  furor,  notably  in  idiots,  epileptics,  and  other 
patients  with  profound  disorder  of  consciousness.  It  is 
always  associated  with  morbid  irritability  and  impulsive- 
ness, of  which  it  is  but  an  expression. 

Morbid  Joy  or  Morbid  Euphoria. — This  presents  itself 
in  two  forms:  one,  a  calm  joy,  analogous  to  passive  depres- 
sion; the  other,  an  active,  exuberant  joy,  analogous  to  active 
depression. 

The  first,  when  of  average  intensity,  manifests  itself 
by  a  state  of  satisfaction,  a  vague  sense  of  well-being.  It 
is  encountered  in  general  paralysis  and  in  certain  forms  of 
tuberculosis.  The  optimism  and  astonishing  contentment 
of  some  consumptives  who  have  reached  the  last  stage  of  their 
illness  are  well-known  phenomena. 

When  calm  euphoria  reaches  its  highest  development 
it  becomes  ecstasy,  in  which  it  is  not  accompanied  by  any 
motor  reaction.  Such  is  the  case  in  certain  forms  of  mystic 
deliria. 

Much  more  frequent  than  this  calm  and  tranquil  form 
of  euphoria,  the  active  form,  noisy,  accompanied  by  motor 
reactions,  is  a  constant  symptom  of  the  so-called  expansive 
forms  of  psychoses:  general  paralysis  with  excitement, 
mania,  certain  toxic  deliria. 

Unlike  depression,  euphoria  permits  of  easy  association 
of  ideas  and  quick  motor  reactions.  These  two  phenomena 
do  not  always  indicate  real  psychic  activity.  In  fact  most 
frequently  in  pathologic  euphoria  the  associations  formed 
are  aimless,  independent  of  all  voluntary  intellectual  activ- 
ity, and  the  motor  reactions  bear  the  stamp  of  impulsive 
acts  originating  automatically. 


DISORDERS  OF  AFFECTIVITY  69 

When  pushed  to  a  certain  degree,  the  apparent  rapidity 
of  association  develops  into  flight  of  ideas  which  has  already- 
been  described.^ 

The  aspect  of  the  patient  in  euphoria  is  the  direct  oppo- 
site of  that  in  depression.  The  expression  is  bright,  smiling, 
with  head  raised  and  body  upright.  The  speech  is  animated 
and  accompanied  by  many  gestures. 

The  concomitant  physical  phenomena  are  in  general 
those  of  joy,  that  is  to  say,  the  reverse  of  those  of  depression. 

First  come  the  cardio-vascular  and  respiratory  phe- 
nomena: peripheral  (and  probably  cerebral)  vaso-dilatation, 
acceleration  of  the  pulse,  increased  force  of  the  cardiac 
impulse,  and  either  elevation  or  lowering  of  the  blood  pres- 
sure, depending  upon  whether  the  increased  heart  action 
does  or  does  not  compensate  for  the  peripheral  vaso-dila- 
tation. 

The  respirations  are  accelerated,  deep  and  regular; 
the  elimination  of  carbon  dioxide  is  increased.  The  general 
nutrition  is  active,  as  is  seen  from  the  patient's  gain  in 
flesh  and  from  the  increase  of  excrementitious  products  in 
the  urine. 

These  different  phenomena,  constant  in  normal  joy 
and  frequent  in  morbid  euphoria,  are,  however,  absent 
in  some  cases,  when  other  factors  are  present  which  counter- 
balance the  favorable  influence  of  joy.  Such  is  the  case 
when  there  is  intense  motor  excitement,  which,  in  spite 
of  the  euphoria,  causes  a  rapid  loss  of  flesh.  Such  is  the 
case  also  when  the  underlying  condition  is  some  severe 
bodily  affection.  The  general  paralytic  or  the  consumptive 
with  euphoria  is  none  the  less  cachectic,  for  in  such  cases  a 
generally  flourishing  state  of  health  is  not  possible. 

Certain  anomalies  are  very  difficult  to  explain.  Some 
maniacs  show,  instead  of  an  acceleration  of  the  pulse  char- 
acteristic of  states  of  euphoria,  a  slowing  which  is  at  times 
quite  marked.     We  have  observed  in  a  young  maniacal 

^See  pp.  50  and  51. 


70  SYMPTOMATOLOGY 

girl  with  marked  excitement  less  than  forty-five  pulsations 
per  minute  for  several  days. 


§  2.    Disorders  of  the  Reactions 

The  different  psychic  operations  which  we  have  so  far 
considered — perception,  association  of  ideas,  affective  phe- 
nomena— find  their  outward  expression  in  the  reactions. 
Like  association  of  ideas,  reactions  may  be  of  two  kinds: 
voluntary  and  automatic. 

Between  a  voluntary  act  accomplished  in  full  self-posses- 
sion and  a  purely  automatic  act  there  are  all  intermediate 
gradations;  we  pass  from  one  to  the  other  by  gradual  insen- 
sible transition.  The  participation  of  the  conscious  will 
diminishes  as  that  of  the  automatism  becomes  more  promi- 
nent, or  inversely. 

We  have  seen  that  in  normal  ideation  voluntary  and 
conscious  associations  tend  to  inhibit  automatic  associa- 
tions. Similarly  the  conscious  will  tends  to  inhibit  auto- 
matic reactions. 

We  shall  study:  (1)  aboulia,  or  paralysis  of  voluntary 
reactions;   and  (2)  automatic  reactions. 

Aboulia. — Complete  paralysis  of  the  will  brings  about, 
depending  upon  the  character  of  the  case,  either  stupor 
or  absolute  automatism.  When  less  pronounced  it  is  mani- 
fested clinically  by  a  general  sense  of  fatigue  and  discour- 
agement, by  slowness  and  unsteadiness  of  the  movements, 
and  by  the  painful  effort  that  is  necessary  for  the  accom- 
plishment of  all  spontaneous  or  commanded  acts.  The 
voluntary  apparatus  then  resembles  a  rusty  mechanism 
which  works  only  with  difficulty. 

Like  sluggishness  of  association,  which  in  most  cases 
accompanies  it,  aboulia  is  a  manifestation  of  psychic  paralysis. 

Automatic  Reactions. — These  may  be  paralyzed  in  the 
same  degree  as  voluntary  reactions  and  give  place  to  the 
absolute  inertia  of  stupor;    or^  on  the  contrary,  they  may 


DISORDERS  OF  THE  REACTIONS  71 

become  exaggerated  by  reason  of  weakening  of  the 
conscious  will. 

We  distinguish:  (A)  positive  automatic  reactions;  and 
(B)  negative  automatic  reactions. 

(A)  Positive  automatic  reactions  are  expressed  clinic- 
ally by  two  phenomena:  suggestibility  and  impulsiveness. 

By  suggestibility  is  understood  a  state  in  which  the 
reactions  are  compelled  by  external  impressions.  Its 
most  perfect  expression  is  catalepsy,  in  which  the  limbs 
assume  and  retain  the  attitudes  in  which  they  are  placed 
by  the  examiner.  This  phenomenon  has  been  termed 
waxy  flexibility  (flexibilitas  cered). 

Many  patients  appear  to  have  lost  all  individual  will 
and  are  reduced  to  mere  automatons.  Some  repeat  exactly 
the  words  (echolalia)  or  the  gestures  (echopraxia)  of  the  per- 
sons around  them.  Others  exhibit  no  spontaneous  activity, 
but  are  able  to  execute  without  hesitation  any  command. 
Such  is  the  case  with  hypnotized  subjects,  certain  catatonics, 
etc.  Sometimes  it  suffices  to  start  them  moving,  when  they 
will  continue  and  accomplish  a  series  of  acts  to  which  they  are 
accustomed. 

Suggestibility  is  the  dominant  note  of  the  character  of 
certain  persons,  mostly  credulous  and  weak-minded,  whose 
thoughts  are  governed  by  external  impressions,  whose  will 
is  nil,  and  who  yield  to  the  domination  of  the  most  diverse 
influences,  good  or  bad.  Many  criminals  belong  to  this 
class. 

Impulsive  reactions  or  impulses  are  to  be  divided  into 
three  groups:  (a)  impulses  of  passion;  (b)  simple  impulses; 
(c)  phenomena  of  stereotypy. 

(a)  Impulses  of  passion  always  depend  upon  abnormal 
irritability.  They  are  determined  by  provocation  that 
is  often  insignificant  and  are  accomplished  independently 
of  any  mental  reflection.  They  are  met  with  in  a  great 
many  patients:  constitutional  psychopaths,  epileptics, 
maniacs,  etc.  A  maniac  feels  his  neighbor  give  him  a  slight 
push;    he  immediately  strikes  him  without  reflecting  that 


72  SYMPTOMATOLOGY 

the  latter  had  no  malevolent  intention,  that  he  was  perhaps 
even  unconscious  of  having  touched  him,  etc.  This  is  an 
impulse  of  passion. 

(6)  Simple  impulses,  purely  automatic,  appear  without 
any  emotional  shock  and  without  a  shadow  of  provocation. 
One  patient  suddenly  threw  into  the  fire  the  gloves,  hat, 
and  handkerchief  of  her  daughter  who  came  to  visit  her  at 
the  sanatorium.  Afterwards  during  a  moment  of  remission 
she  remembered  perfectly  the  act  and  the  circumstances 
under  which  it  was  accomplished,  but  was  not  able  to 
furnish  any  explanation  for  it. 

The  impulse  may  be  conscious.  A  patient  is  suddenly 
seized  with  a  strong  desire  to  steal  some  object  from  a  show- 
window,  the  possession  of  which  could  be  neither  useful  nor 
pleasant  to  liim;  he  does  not  yield  to  this  impulse,  which  he 
recognizes  as  pathological.  This  is  a  conscious  impulse. 
This  phenomenon  is  closely  allied  to  imperative  idea,  of  which 
it  is  but  an  accentuation. 

(c)  Stereotypy  consists  in  a  morbid  tendency  to  retain 
the  same  attitude,  or  to  repeat  the  same  movement  or  the 
same  words.      Hence  the  three  kinds  of  stereotypy: 

Stereotj'py  of  attitudes; 

Stereotyp}^  of  movements; 

Stereotypy  of  language:  verbigeration. 

Certain  patients  remain  for  hours  at  a  time  in  most 
uncomfortable  attitudes;  others  will  walk  a  long  distance, 
taking  alternately  three  steps  forward  and  two  backward; 
still  others  will  repeat  indefinitely  the  same  phrase  or  the 
same  verse. 

(B)  Negative  Automatism. — This  forms  the  basis  of 
negativism  and  consists  in  the  annulment  of  a  voluntary 
normal  reaction  by  a  pathological  antagonistic  tendency. 

The  patient  is  requested  to  give  his  hand;  the  voluntary 
reaction  which  tends  to  appear  and  which  would  result 
in  compUance  with  the  request,  is  arrested,  suppressed  by 
automatic  antagonism.  This  disorder  of  the  will  has  been 
designated   by    Kraepelin,    who   has   made    an   admirable 


DISORDERS  OF  CCENESTHESIA  73 

study  of  it,  by  the  term  Sperrung,  a  word  which,  Hterally 
translated  into  EngHsh,  means  blocking.  A  more  significant 
term  perhaps  would  be  psychic  interference.  The  two 
antagonistic  tendencies  neutralize  each  other  like  inter- 
fering sound-waves  in  physics. 

On  a  superficial  examination  negativism  may  resem- 
ble aboulia.  These  are,  however,  two  very  different  phe- 
nomena. While  the  latter,  purely  passive,  is  the  result  of 
persistent  paralysis  against  which  the  patient  struggles  with 
more  or  less  success,  the  former,  an  active  phenomenon, 
depends  not  upon  paralysis  but  upon  a  perversion  of  the 
will.  Negativism  is  often  manifested  only  in  certain  kinds 
of  reactions.  One  patient  who  walks  about  without  any 
effort  does  not  open  his  mouth.  Another  who  dresses 
himself,  eats  unassisted,  and  even  works,  remains  in  com- 
plete mutism,  making  no  response  in  spite  of  all  perseverance 
on  the  part  of  the  questioner. 

In  a  more  marked  degree  negative  automatism  results 
not  only  in  the  arrest  of  normal  reactions,  but  also  in  the 
production  of  contrary  reactions. 

Thus  if  one  attempts  to  flex  the  patient's  head  he  extends 
it,  and  vice  versa.  If  he  is  requested  to  open  his  half-shut 
eyes  he  closes  them,  and  if  the  examiner  attempts  to  force 
them  open,  his  orbicularis  muscle  contracts  in  a  veritable 
spasm.  Wernicke  observed  that  while  flexibilitas  cerea 
chiefly  shows  itself  in  the  limbs,  negativism  mostly  affects 
the  muscle  groups  of  the  head  and  neck. 


§  3.     Disorders  of  Ccenesthesia  and  of  the 
Personality 

Disorders  of  Coenesthesia. — By  ccenesthesia  or  vital 
sense  is  understood  ''  the  general  feehng  which  results  from 
the  state  of  the  entire  organism,  from  the  normal  or  abnormal 
progress  of  the  vital  functions,  particularly  of  the  vegetative 
functions"    (Hoffding).     The   stimuH   which   produce   this 


74  SYMPTOMATOLOGY 

sense  are  vague  and  poorly  localized,  and  are  perceived  not 
individually,  but  together  as  a  whole. 

The  harmony  which  normally  exists  between  the  diverse 
organic  functions  produces  a  vague  sense  of  satisfaction  and 
of  well-being.  All  causes  tending  to  destroy  this  harmony 
will  produce  in  consciousness  a  feeling  of  malaise  and  of 
suffering  more  or  less  definite  and  more  or  less  acute.  Thus 
the  disorders  of  coenesthesia  are  intimately  connected  with 
disorders  of  affectivity;  most  of  the  depressed  states  have  for 
their  basis  an  alteration  of  the  vital  sense. 

Disorders  of  the  Personality. — Alterations  of  the  per- 
sonality constitute  the  symptom  which,  following  Wernicke, 
we  have  termed  autopsychic  disorientation. 

These  disorders  may  be  arranged  in  three  principal 
groups : 

(a)  Weakening  of  the  notion  of  personality; 

(6)  Transformation  of  the  personality; 

(c)   Reduplication  of  the  personality. 

(a)  The  notion  of  personality  may  be  incomplete  or 
absent;  it  may  have  never  been  developed  at  all,  or  it 
may  have  been  but  incompletely  developed,  as  in  idiots 
and  imbeciles,  or  it  may  have  disappeared  or  become 
weakened  under  the  influence  of  a  pathogenic  cause,  as 
in  mental  confusion,  epileptic  delirium,  depression  with 
stupor,  etc. 

(6)  Transformation  of  the  personality  may  be  complete 
or  incomplete. 

In  the  first  case  the  patients  forget  or  deny  everything 
pertaining  to  their  former  personality.  Thus  one  patient 
claimed  that  she  was  Mary  Stuart,  wanted  to  be  addressed 
as  "  Her  Majesty  the  Queen  of  Scotland,"  and  attired  her- 
self in  costumes  sunilar  to  those  of  that  time.  She  becaine 
furious  when  called  by  her  own  name,  and  obstinately 
refused  to  accept  the  visits  of  her  husband  and  children, 
whom  she  called  "  impostors."  Another  patient,  afflicted 
with  hysteria,  believed  herself  to  have  been  transformed 
into   a  dog;    she  barked  and  walked   on  all  fours.     Still 


DISORDERS  OF  THE  PERSONALITY  75 

another  patient  at  the  Salpetriere  referred  to  herself  as  "  the 
person  of  myself." 

Complete  transformation  of  the  personality  may  be  'per- 
manent, constituting,  according  to  the  excellent  expression 
of  Ribot,  a  true  alienation  of  the  personality;  or  it  may  be 
transitory,  so  that  the  new  ego  disappears  at  a  certain  time  to 
be  replaced  again  by  the  former  ego.  In  cases  in  which  the 
normal  personality  and  the  pathological  one  replace  each 
other  mutually  several  times  we  have  variation  by  alter- 
nation.i 

Incomplete  transformation  of  the  personality  exists  in 
a  great  many  cases  in  which  the  patients  are  led  by  their 
delusions  to  attribute  to  themselves  imaginary  talents, 
powers,  or  titles,  without  at  the  same  time  completely 
abolishing  their  real  ego.  One  patient  suffering  from  a 
chronic  delusional  state  of  old  standing  claimed  that  he 
was  St.  Peter,  and  explained  that  he  had  been  incarnated 
in  an  earthly  man  for  the  purpose  of  bringing  happiness 
to  mankind.  A  general  paralytic  claimed  that  he  was 
Emperor  of  Asia,  reigning  in  Pekin,  being  at  the  same  time 
aware  of  the  fact  that  he  was  living  in  Paris,  and  was  a 
newspaper  vendor. 

(c)  Reduplication  of  the  personality  consists  in  the  develop- 
ment of  a  new  personality  of  a  parasitic  nature  alongside 
of  the  real  personality  of  the  patient. 

This  reduplication  is  the  origin  of  the  idea  of  possession 
so  frequent  in  chronic  delusional  states  and  results  in  a 
psychic  disaggregation  the  most  important  manifestations 
of  which  are  autochthonous  ideas  (psychic  hallucinations) 
and  motor  hallucinations.  As  we  have  had  occasion  to 
indicate  above,  the  patient,  feeling  that  he  is  losing  control 
of  his  own  thoughts  and  movements,  concludes  that  a 
strange  personality  has  taken  possession  of  him. 

^  Ribot.    The  Diseases  of  Personality. 


CHAPTER   V 

THE  PRACTICE  OF  PSYCHIATRY 
HISTORY  TAKING— METHODS  OF  EXAMINATION 

The  data  for  diagnosis,  prognosis,  and  treatment  are 
obtained  in  psychiatry,  as  in  other  branches  of  medicine, 
from  the  case  history  and  from  the  direct  examination  of 
the  patient. 

§  1.    History  Taking 

Information  must  be  sought  from  all  available  sources 
and  the  various  data  checked  against  each  other  to  insure 
accuracy  as  far  as  possible. 

The  patient  himself,  if  able  and  willing  to  cooperate, 
can  often  furnish  information  that  is  of  the  most  intimate 
kind  and  not  to  be  had  from  other  informants;  this  is 
especially  true  in  regard  to  the  sexual  life  and  venereal 
infections.  Besides,  it  is  always  useful  to  have  a  free 
expression  of  the  patient's  viewpoint,  even  if  the  statements 
made  by  him  are  incorrect. 

Further  information  is  to  be  sought  from  the  patient's 
relatives  and  friends  and,  in  a  case  presenting  a  history  of 
previous  admissions,  from  the  records  of  the  institutions  in 
which  he  was  treated. 

Efforts  to  secure  a  case  history  should  not  stop  here, 
as  they  do  too  commonly.  It  is  now  widely  recognized  that 
a  satisfactory  knowledge  of  the  family  history  and  of  the 
nature  of  the  environment,  in  the  midst  of  which  the  patient 
has  lived  and  developed  his  psychosis,  is  hardly  to  be  had 

76 


HISTORY  TAKING  77 

without  field  investigation,  affording  opportunities  of  inter- 
viewing relatives,  friends,  neighbors,  family  physicians, 
employers,  and  others  who  do  not  visit  the  hospital;  con- 
sulting public  records  of  births,  marriages,  divorces,  and 
deaths;   and  studying  at  first  hand  the  home  conditions. 

These  considerations,  as  well  as  others  pertaining  to  social 
service  and  after-care  of  paroled  or  discharged  patients, 
have  led  to  the  growing  practice  of  employing  social  workers 
in  institutions. 

Family  History .^ — A  full  family  history  in  a  given  case 
may  be  of  value  not  only  for  a  study  of  its  etiology,  but  also 
for  the  assistance  that  is  at  times  to  be  derived  from  it  in 
the  interpretation  of  clinical  manifestations. 

The  questioning  should  be  systematic,  taking  up  mem- 
bers of  the  family  individually,  and  covering  wherever 
possible  at  least  the  patient's  children,  brothers  and  sisters, 
nephews  and  nieces,  parents,  and  grandparents,  uncles,  aunts, 
and  cousins  on  both  the  paternal  and  maternal  sides. 

For  each  member  of  the  family  it  is  desirable  to  place 
on  record  the  name,  sex,  birthplace,  age  (or  age  at  time  of 
death),  cause  of  death,  education,  occupation,  and  marital 
condition. 

As  special  subjects  of  inquiry  may  be  mentioned  the 
following :  psychoses,  a  description  to  be  secured  in  each  case 
of  time  and  manner  of  onset,  principal  manifestations,  course, 
termination,  and  recurrences;  epilepsy  and  other  disorders 
which  seem  to  be  related  to  it,  namely,  convulsions  in  child- 
hood, fainting  spells,  migraine,  and  periodic  dipsomania; 
arrests  of  development,  as  shown  by  delayed  walking  and 
talking  not  due  to  physic?.!  causes,  poor  record  at  school, 
lack  of  success  in  work;  suicide,  method  and  immediate 
cause  to  be  given  if  known;  the  milder  psychoses,  "  nervous 
prostration,"  and  psychoneuroses,  hysteria,  neurasthenia, 
psychasthenia;    addictions  to  alcohol  or  drugs,  details  to  be 

1 C.  B.  Davenport,  in  collaboration  with  others.  The  Family 
History  Book.  Bulletin  No.  7.  Eugenics  Record  Office,  Cold  Spring 
Harbor,  N.  Y.,  1912. 


78  THE  PRACTICE  OF  PSYCHIATRY 

given  of  amounts  and  frequency  of  indulgence,  periods  of 
abstinence,  etc.;  anti-social  traits,  criminality,  mendacity, 
prostitution,  vagrancy,  pauperism  not  dependent  on  phys- 
ical causes;  temperamental  anomalies,  such  as  undue  irrita- 
bility, spells  of  "  the  blues,"  worrisome  or  hypochondriacal 
disposition,  excessive  religious  preoccupation,  miserUness, 
and  other  eccentricities;  sexual  anomalies,  especially  per- 
versions and  inversions;  and  finally  conditions  like  asthma, 
sick  headaches,  and  recurrent  vomiting,  the  relation  of  which, 
if  there  be  any,  to  the  neuropathic  states,  is  not  clearly  estab- 
lished. 

The  fact  of  a  sojourn  for  treatment  or  custody  in  a 
hospital,  sanatorium,  asylum,  colony  for  the  epileptic  or 
feeble-minded,  or  almshouse,  or  of  imprisonment  in  a 
penal  institution,  should  be  recorded  wherever  ascertained 
with  dates  and  other  details. 

In  connection  with  cases  of  Huntington's  chorea  only 
similar  heredity  seems  to  be  of  significance;  hence  inquiry 
should  be  especially  directed  to  other  cases  of  chorea  in  the 
family. 

In  cases  like  juvenile  general  paralysis,  the  question  of 
congenital  syphilis  may  arise,  which  the  family  history 
should,  of  course,  help  to  clear  up. 

It  is  not  enough  to  state  in  each  case  merely  the  alleged 
fact  of  the  existence  of  one  or  more  of  the  above-mentioned 
conditions;  but  wherever  anything  of  the  sort  is  found 
a  description  in  terms  of  the  conduct  and  life  course  of  the 
individual  should  be  given,  sufficient  to  establish  the  fact  as 
alleged. 

Personal  History. — Here  the  main  topics  of  inquiry  are : 
(a)  Were  there  any  conditions  during  intra-uterine  life 
(infections,  eclampsia,  traumatisms  of  the  mother;  hydro- 
cephalus or  other  diseases  of  the  foetus),  at  birth  (premature 
labor,  difficult  or  instrumental  delivery  with  resulting  head 
injury),  or  in  infancy  or  childhood  (meningitis,  whooping  cough 
with  intracranial  complications)  likely  to  interfere  with  the 
mental  development?     (6)  Were  there  at  any  time  prior  to 


HISTORY  TAKING  79 

the  onset  of  the  mental  disorder  any  abnormalities  in  the 
patient's  constitutional  make-upf  Convulsions  in  infancy, 
childhood,  or  later;  fainting  spells;  delayed  walking  or  talk- 
ing; poor  record  at  school,  lack  of  success  in  work;  anti-social 
traits  (criminality,  mendacity,  prostitution,  vagrancy) ;  tem- 
peramental anomalies  (undue  irritability,  spells  of  ''  the 
blues,"  worrisome  or  hypochondriacal  disposition,  seclu- 
siveness,  excessive  religious  preoccupation,  miserliness,  or 
other  eccentricities);  and  sexual  anomalies  (masturbation, 
perversions,  inversions).^  (c)  What  were  the  patient's 
habits  in  regard  to  the  use  of  alcohol?  What  has  led  to  its 
use?  (Domestic  infelicity,  being  out  of  work,  business 
reverses,  sociability?)  Was  its  use  regular  (daily,  week 
ends)  or  only  occasional?  What  were  the  beverages  used? 
(Beer,  wine,  whiskey.)  In  what  quantities  were  they  used? 
Did  he  go  on  sprees?  Did  he  become  intoxicated,  if  so,  how 
often?  Did  the  drinking  affect  the  patient's  appetite  or 
health  in  any  way?  Did  it  cause  him  to  lose  time  from  his 
regular  occupation?  A  particularly  detailed  account  should 
be  obtained  for  the  time  immediately  preceding  the  onset 
of  the  psychosis,  (d)  Detailed  information  should  be  sought 
concerning  venereal  infections,  particularly  syphilis;  date 
and  source  of  infection,  manifestations;  was  treatment 
prompt?  of  what  did  it  consist?  was  it  thorough?  was  it 
systematic,  prolonged,  and  serologically  controlled?  did  the 
serological  tests  ultimately  become  and  remain  negative? 
(e)  Did  the  patient  ever  suffer  a  head  injuryf  Did  he 
become  unconscious  either  immediately  following  the  injury 
or  after  an  interval?  How  long  did  the  unconsciousness 
last?  What  symptoms  were  observed  after  recovery  of 
consciousness?  Was  there  a  fracture  of  the  skull?  Was  the 
patient  operated  on?  Did  he  eventually  recover  fully  from 
the  effects  of  the  injury?  (/)  Obtain  a  description  of  the 
patient's  bringing  up,  his  sexual,   domestic,  marital,   and 

^  August  Hoch  and  G.  S.  Amsden.  A  Guide  to  the  Descriptive  Study 
of  the  Personalitrj.  N.  Y.  State  Hosp.  Bulletin,  N.  S.,  Vol,  VI,  1913, 
p.  344. 


80  THE  PRACTICE  OF  PSYCHIATRY 

business  life  with  a  view  to  determining  whether  there  were 
any  other  pathogenic  influences  such  as  have  already  been 
mentioned  in  the  chapter  on  Etiology  under  the  heading 
of  incidental  or  contributing  causes. 

History  of  Psychosis. — Were  there  any  previous  attacks 
of  mental  trouble?  What  were  the  cause,  date  and  mode  of 
onset,  principal  manifestations,  course,  duration,  and  out- 
come of  each?  What  was  the  immediate  cause  of  the  present 
attack?  The  date  of  its  onset  and  the  manner,  i.e.,  whether 
sudden  or  gradual?  Earliest  observed  manifestationsf 
Principal  features?  What,  if  any,  was  the  treatment  of  the 
attack  prior  to  the  patient's  admission  to  the  hospital? 
What  led  to  the  patient's  commitmentf 

In  cases  of  constitutional  psychoses  a  neuropathic 
family  history  and  evidence  of  abnormal  make-up  are  now 
generally  accepted  as  accounting,  in  a  measure,  merely  for 
the  fact  that  a  psychosis  has  occurred,  but  not  as  explaining 
why  it  occurred  at  the  particular  time  when  it  did,  nor  its 
special  content  and  other  manifestations.  A  case  history 
is  imperfect  which  fails  to  connect  specific  environmental 
happenings  with  the  development  of  symptoms,  both 
chronologically  and  by  content.  It  will  be  granted,  of  course, 
that  in  many  cases,  owing  to  a  sjniibolic  nature  of  the  trends 
or  reactions,  the  etiologic  mechanism  is  veiled;  but  this 
should  not  prevent  an  attempt,  at  least,  to  seek  out  the 
connections  which,  it  must  be  assumed,  exist  in  every  case. 

§  2.     Methods  of  Examination 

Physical  Examination. — Height,  weight  (compared  with 
usual  weight),  malformations  (especially  of  skull),  general 
state  of  nutrition,  pallor  (haemoglobin  estimation  and  cell 
count,  if  indicated),  temperature,  pulse,  respiration,  appe- 
tite, condition  of  the  bowels,  sleep,  menstrual  function; 
subjective  complaints  (vertigo,  headache,  pains,  weakness); 
cyanosis,  dropsy,  jaundice,  eruptions;  scars  or  other  evi- 
dences of  old  or  recent  injury.     Heart,  lungs,  abdominal  or- 


METHODS  OF  EXAMINATION  81 

gans,  urine ;  vaginal  examination ;  pulse  rate  at  rest  and  after 
exercise;  blood  pressure.  Nervous  system:  smell,  hearing, 
taste,  cutaneous  sensibility;  vision,  errors  of  refraction, 
hemianopsia,  ophthalmoscopy  if  indicated;  nystagmus, 
strabismus;  pupils — equal  or  unequal,  regular  or  irregular 
in  outline,  reaction  to  light  normal  or  sluggish  or  sUght  in 
excursion,  reaction  to  distance ;  innervation  of  facial  muscles 
— equal  or  asymmetrical;  grips  in  the  two  hands — equal  or 
unequal  (dynamometer  test);  strength  of  legs  (for  test  of 
weakness  of  one  lower  extremity  have  both  lower  extremities 
raised  and  held;  the  weaker  limb  will  sink  before  the  other); 
coordination — writing,  buttoning  coat,  gait,  Romberg  sign, 
balancing  power  on  either  foot;  reflexes — knee  jerks,  with  and 
without  Jendrassic  reinforcement  (normal,  unequal,  exag- 
gerated, diminished,  lost),  ankle  clonus,  plantar  reflex 
(Babinski  sign),  sphincter  control;  tremors — eyelids,  lips, 
tongue,  hands — fine,  coarse,  intention  (handwriting);  chore- 
iform or  athetoicl  movements;  speech — stuttering,  slurring, 
scanning  (test  phrases;  third  riding  artillery  brigade,  partic- 
ular popularity,  Methodist  Episcopal);  aphasia  (systematic 
examination  if  indicated);  convulsions — frequency,  loss  or 
preservation  of  consciousness,  localized,  or  general,  with  or 
without  aura,  biting  of  tongue,  voiding  of  urine,  followed  by 
stupor  or  prompt  recovery. 

Mental  Examination.^ — Much  of  value  can  be  learned 
on  a  patient's  coming  before  the  examining  physician  from 
his  general  appearance,  manner,  and  spontaneous  utterances: 
his  appearance  may  be  disheveled,  neglected,  untidy;  he 
may  seem  dejected,  or  irritable,  or  happy,  or  apathetic;  he 
may  cooperate  in  the  hospital  routine,  showing  a  more  or 
less  intelligent  adaptation;  or  merely  submit  in  a  passive 
way  to  being  undressed,  bathed,  etc.;  or  he  may  be  resistive 
and  violent;  he  may  be  taciturn  or  even  mute,  failing  to 
respond  to  any  question,  or  he  may  be  talkative,  protesting, 

^  Sommer.  Diagnostik  der  Geisteskrankheiten.  Berlin  and  Vienna, 
1901. — Fuhrmann.  Diagnostik  und  Prognostik  der  Geisteskrankheiten. 
Leipsic,  1903. 


82  THE  PRACTICE  OF  PSYCHIATRY 

or  complaining,  or  wailing,  or  merely  commenting  on  things 
about  him,  perhaps  showing  disturbances  ia  the  flow  of 
thought  like  distractibility,  flight  of  ideas,  incoherence, 
verbigeration. 

The  manner  of  the  cliaical  examination  proper  will  depend 
to  a  considerable  extent  on  the  nature  of  the  case  and  the 
amount  of  cooperation.  In  an  irresponsive,  seemingly 
stuporous  case,  or  in  one  presenting  great  excitement  a 
complete  mental  examination  is  out  of  the  question  for  the 
time  being  and  can  be  attempted  only  after  subsidence  of  the 
hyper-acute  phenomena.  It  should  be  borne  in  mind, 
however,  that  a  condition  of  seeming  stupor  may  prove 
to  be  either  one  of  marked  depression  or  of  catatonic  nega- 
tivism with  well-preserved  lucidity.  A  detailed  record 
should  be  made  of  the  condition  found,  especially  of  any 
unexplained  peculiarities  in  attitude  or  conduct,  to  be  dis- 
cussed with  the  patient  when  better  cooperation  is  to  be  had. 

In  cases  offering  reasonable  cooperation  it  is  of  great 
advantage  to  proceed  systematically.  Some  patients  volun- 
teer to  tell  their  story  as  soon  as  they  are  brought  into  the 
examining  room,  which  they  should  be,  of  course,  encouraged 
to  do ;  others  will  speak  only  when  questioned,  and  then  but 
briefly.  In  any  case  it  is  desirable,  before  actual  testing  is 
begun  or  any  specific  questioning  concerning  hallucina- 
tions or  delusions,  to  get  the  patient's  account  of  his  trouble 
or  at  least  of  the  situation  which  led  to  his  commitment. 
Should  he  show,  in  the  course  of  his  account,  a  tendency  to 
ramble  from  his  subject,  or  any  disconnectedness,  or  other 
disturbance  of  the  flow  of  thought,  then  it  is  very  useful  to 
make  an  exact  stenographic  record  of  a  sample  of  his  utter- 
ances to  the  extent,  say,  of  half  a  page  or  a  page;  that 
being  done,  he  may  be  assisted  by  the  examiner  by  being 
interrupted  whenever  necessary  and  reminded  of  the  points 
on  which  he  was  asked  to  give  information. 

It  is  very  important  to  have  the  patient  at  his  ease  as 
far  as  possible,  not  to  arouse  his  antagonism  or  suspicion  or 
apprehension.     The  only  correct  way  of  approaching  him 


METHODS  OF  EXAMINATION  83 

is  with  perfect  candor,  letting  him  understand  that  the  ex- 
aminer is  Dr.  ,  a  physician,  a  speciahst  in  nervous 

and  mental  diseases,  and  that  the  object  of  the  examination 
is  to  find  out  if  he  has  not  some  such  trouble. 

Thus  one  may  begin  with  such  questions  as,  Tell  me 
about  your  case;  have  you  been  sick?  Did  you  have  any 
trouble  at  home?  Why  have  they  brought  you  here? 
Have  you  been  ill-treated? 

As  the  next  step  the  patient  may  be  questioned  about 
the  statements  in  the  commitment  paper  made  to  show 
insanity  and  necessity  of  commitment,  and  from  that  it  is 
easy  to  pass  to  direct  questions  concerning  hallucinations  or 
delusions,  following  the  leads  made  available  by  his  account: 
Have  you  heard  voices?  Has  anyone  hypnotized  you?  Do 
people  talk  about  you?  Do  they  read  your  mind?  Have 
you  been  poisoned?  Are  you  followed  by  detectives?  Is  it 
true  that  you  are  very  wealthy? 

It  goes  without  saying  that  any  hallucinations  or  delu- 
sions that  may  be  elicited  should  be  gone  into  thoroughly: 
Do  you  hear  the  voices  all  the  time  or  only  occasionally? 
Are  they  distinct?  Are  they  voices  of  men  or  of  women? 
Familiar  or  strange?  Where  do  they  come  from?  Trans- 
mitted by  some  apparatus?  What  do  they  say?  What  do 
you  do  when  you  hear  them?  Do  others  hear  them  also  or 
only  you?  Don't  you  think  it  is  just  imagination?  Or, 
What  makes  you  think  you  are  being  poisoned?  Did  you 
taste  it  in  your  food?  Have  you  noticed  any  ill  effects? 
Who  is  doing  it?  For  what  reason?  For  what  object? 
What  do  you  plan  to  do  about  it? 

At  this  stage  of  the  interview  the  examiner  will  probably 
already  have  gained  some  idea  of  the  patient's  orientation, 
memory,  education,  and  mental  capacity.  But  it  is  prefer- 
able to  test  these  specially  and  by  a  uniform  technique  for 
all  cases  in  order  to  obtain  data  for  comparison.  The  fol- 
lowing questions  are  recommended: 

What  is  your  name? 
Where  were  you  born? 


84  THE  PRACTICE  OF  PSYCHIATRY 

In  what  year  were  you  born? 

What  year  is  this? 

How  old  does  that  make  you? 

What  is  your  occupation? 

Where  do  you  live? 

What  is  the  name  of  this  town  or  city? 

How  far  is  it  from  New  York  (or  other  notable  city)? 

What  kind  of  an  institution  is  this? 

What  date  is  to-day?     What  month?     What  day  of  the  week? 

Is  this  morning  or  afternoon? 

Where  did  you  come  from?     When? 

How  did  you  come  (train,  boat,  trolley,  carriage,  walk)? 

Did  you  come  alone  or  with  somebody? 

What  did  you  have  for  breakfast  this  morning? 

Where  were  you  yesterday? 

Where  were  you  a  week  ago? 

Where  were  you  last  Christmas? 

Where  did  you  go  to  school?     Can  you  name  some  of  your  teachers? 

When  did  you  leave  school? 

When  did  you  begin  work? 

Who  was  your  first  employer? 

Count  backwards  from  20  to  1. 

5+4?     9+7?     26+39?     4X8?     5X12?     9X17? 

Give  the  months  of  the  year. 

Name  five  large  cities  in  the  United  States. 

Where  is  London?     Paris?     Berlin?     Vienna?     Rome? 

Who  is  the  President  of  the  United  States?     Who  was  the  first 

President?    What  war  took  place  while  Abraham  Lincoln  was 

President? 

Retention  may  be  tested  by  giving  the  patient  a  number, 
or  a  name,  or  a  phrase  to  remember  (1473,  physician's 
name,  238  Main  Street),  and  asking  him  to  recall  it  at  the 
end  of  five  minutes. 

At  some  convenient  time  during  the  examination  an 
attempt  should  be  made  to  determine  the  degree  of  insight 
which  the  patient  has  in  regard  to  the  abnormal  nature  of 
his  symptoms.  It  happens  very  seldom  that  .a  patient 
admits  that  he  is  insane,  but  this  is  hardly  a  proper  criterion 
of  insight ;  in  fact  where  it  does  happen  it  is  more  apt  to  be 
dependent  on  a  certain  shallowness  of  personality  and  emo- 
tion than  on  a  real  preservation  of  auto-critical  faculty. 


METHODS  OF  EXAMINATION  85 

Thus  one  imbecile  was  asked,  Why  did  they  send  you  here? — 
"  They  said  I  was  crazy,"  he  answered.  Was  that  really 
so?  he  was  asked  again. — "  I  guess  so,"  he  said,  grinning  all 
the  time. — What  is  of  importance  in  this  connection  is  to 
gain  a  precise  idea  to  what  extent  the  patient  realizes  the 
unusualness  of  his  morbid  experiences  and  behavior  and  their 
dependence,  not  necessarily  on  insanity,  but  on  being  "  ner- 
vous," or  "  upset,"  or  on  "  overwork,"  or  "  lack  of  sleep," 
or  "  drinking  too  much,"  etc. 

Tests  of  reading  and  writing  are  also  very  useful. 

The  first  consists  in  requesting  the  patient  to  read  aloud 
some  paragraph  in  a  book  or  in  a  newspaper  and  then 
having  him  give  an  account  of  what  he  has  read ;  his  account 
is  more  or  less  accurate  and  complete.  This  test  may  demon- 
strate any  existing  disorders  of  (1)  perception;  (2)  attention 
and  association  of  ideas;  (3)  power  of  fixation;  (4)  speech 
(physical  impediments) . 

A  systematic  study  of  the  writings  of  psychotic  patients 
is  of  the  highest  interest.  The  symptoms  which  such 
writings  reveal  are  sometimes  so  clear  as  to  be  sufficient 
in  themselves  to  characterize  an  affection,  and  in  all  cases 
they  constitute  valuable  elements  of  diagnosis.  Joffroy  has 
very  properly  classified  them  into  calligraphic  and  psycho- 
graphic  disorders.  The  former  pertain  to  the  handwriting 
as  such,  which  may  be  more  or  less  irregular,  tremulous, 
hesitating,  etc.  The  latter  pertain  to  the  content  of  the 
writing  and  reveal  psychic  abnormalities:  weakening  of 
attention  (omission  of  words,  syllables,  or  letters,  errors 
of  spelling  due  to  inattention),  weakening  of  memory  (errors 
of  spelling  due  to  effacement  of  word  images  or  to  forgetting 
the  rules  of  grammar),  mental  automatism  (flight  of  ideas, 
incoherence,  stereotyped  repetition  of  letters,  words,  or 
phrases),  and  various  delusions. 

The  writings  constitute  trustworthy,  permanent  docu- 
ments which  may  be  indefinitely  preserved  as  evidence  of 
the  state  of  psychic  (sometimes  also  of  motor)  functions  of 
a  patient  at  a  given  time.     One  may  also,  with  the  aid  of  the 


86  ■  THE  PRACTICE  OF  PSYCHIATRY 

data  of  graphic  pathology  and  solely  by  means  of  examining 
the  writings  of  a  subject,  follow  in  a  certain  measure  the 
course  of  a  mental  disease  the  development  of  which  is 
either  progressive,  as  general  paralysis,  or  cychc,  as  some 
manic-depressive  psychoses. 

From  the  standpoint  of  symptomatology  four  kinds 
of  writings  may  be  distinguished:  spontaneous  writings, 
writings  from  copy,  writings  from  dictation,  and  penman- 
ship. Each  has  its  special  interest,  as  each  enables  us  to 
study  particular  types  of  pathological  phenomena.  Spon- 
taneous writings  reveal  chiefly  the  delusions  of  patients  and 
are  often  of  great  value  in  cases  of  dissimulation.  Writing 
from  copy  reveals  disorders  of  attention,  and  writing  from 
dictation  reveals  disorders  of  memory.  Finally  penmanship, 
which  results  from  the  patient's  effort  to  produce  the  best 
possible  handwriting,  brings  out  motor  disorders  (tremor 
and  ataxia) . 

Unfortunately  the  study  of  graphic  pathology  in  order 
to  be  fruitful  must  go  into  certain  details  which  could  not  be 
entered  upon  here  for  want  of  space.  We  must  therefore 
limit  ourselves  to  this  brief  discussion  and  refer  the  student 
to  works  in  which  this  subject  is  specially  treated. ^ 

Having  completed  the  examination  it  will  be  found 
very  advantageous  to  prepare  a  summary  of  the  findings 
which  are  of  significance  for  diagnosis,  prognosis,  and 
treatment. 

Many  attempts  have  been  made  to  simplify  and  standard- 
ize the  work  of  clinical  examinations  by  the  use  of  printed 
blank  forms.  Experience  has  shown  that  to  rely  entirely  on 
records  thus  prepared  is  not  consistent  with  good  clinical 
work.     For  a  part  of  the  records,  however,  it  will  be  found 

^  Seglas.  Les  troubles  du  langage  chez  les  alienes.  Bibliotheque 
Charcot-Debove. — Koster.  Die  Schrift  bei  Geisteskrankheiten.  Leip- 
zig, 1902. — Joffroy.  Les  troubles  de  la  lecture,  de  la  parole,  et  de  I'ecriture 
chez  les  paralytiques  generaux.  Nouv.  Iconogr.  de  la  Salpet.  Nov.- 
Dec.  1903. — J.  Rogues  de  Fursac.  Les  ecrits  et  les  dessins  dans  les 
maladies  nerveuses  et  mentales.     Paris,  Masson,  1905- 


METHODS  OF  EXAMINATION  87 

helpful  to  have  a  statistical  data  sheet  or  card  such  as  is  used 
in  the  New  York  state  hospital  service,  somewhat  like  the 
following: 

Patient's  name  in  full Admission  No 

Date  of  admission 191       Race Sex 

Residence Date  of  birth 

Marital  condition  (single,  married,  widowed,  divorced,  separated). 
Occupation   (or  that  of  husband,   father,  or  other  person  on  whom 

patient  is  dependent) Citizenship    (American, 

foreign) . 

Nativity  (state  or  country) How  long  in  U.  S 

Nativity  of  father of  mother 

Education  (none,  reads  only,  reads  and  writes,  common  school,  high 

school,  collegiate,  professional).     Religion  (denomination) 

Previous  hospital  residences  (dates  and  duration  of  each) 

Heredity 

Constitutional  make-up  (intellectually  and  temperamentally) 


Alcoholic  habits 

Venereal  history 

Other  etiological  factors 

Date  and  manner  of  onset  of  psychosis 

Diagnosis Legal  status  (committed,  voluntary) 

Permission  for  autopsy  in  event  of  death 

Names  and  addresses  of  relatives,  friends,  or  legal  guardians :  . . . . 


CHAPTER  VI 

THE  PRACTICE  OF  PSYCHIATRY  {Continued) 

SPECIAL  DIAGNOSTIC  PROCEDURES:  LUMBAR  PUNCTURE 
—WASSERMANN  REACTION— CHEMICAL  TESTS— IN- 
TELLIGENCE TESTS—EXAMINATION  FOR  APHASIA- 
ASSOCIATION  TESTS— OTHER  TESTS— MEDICAL  CON- 
SULTATIONS 

It  is  not  to  be  supposed  that  the  case  histoiy  and  cUnical 
examination,  obtained  by  the  methods  outhned  in  the  pre- 
ceding chapter,  will  complete  the  investigation  of  every 
case.  Very  often  these  methods  afford  but  leads  to  further 
investigation  by  special  methods  according  to  the  indications 
presenting  themselves  in  the  case  imder  consideration.  A 
suspicion  of  syphihs,  for  instance,  can  by  no  means  be  defi- 
nitely dismissed  b}'-  a  denial  made  either  by  the  patient  or 
other  informants;  the  differentiation  between  certain  alco- 
hoKc  psychoses,  neurasthenia,  arteriosclerotic  dementia, 
and  other  conditions,  on  the  one  hand,  and  general  paralysis, 
on  the  other,  cannot  always  be  made  with  certainty  without 
the  aid  of  special  diagnostic  procedures;  the  intellectual 
make-up  of  a  patient  cannot  be  determined  with  any  degree 
of  accuracy  without  resort  to  measurement  by  means  of 
the  Binet-Simon  or  other  appropriate  ps3''chological  tests. 

Lumbar  Puncture. — Lumbar  puncture  is  a  simple  and 
harmless  procedure.  The  only  danger,  that  of  infection, 
can  be  entirely  avoided  by  the  exercise  of  ordinary  pre- 
cautions of  asepsis. 

It  is,  however,  contraindicated  in  cases  of  great  general 
weakness  and  in  those  in  which  there  is  evidence  of  abnor- 

88 


SPECIAL  DIAGNOSTIC  PROCEDURES  89 

mally  high  intracranial  pressure  (brain  tumor).  In  such 
cases  there  is  possibiHty  of  fatal  issue. ^ 

The    examination   of   cerebro-spinal   fluid   obtained   by 

'  lumbar    puncture    for    purposes    of    psychiatric    diagnosis 

usuallj^  consists  of  the  following  procedures:    (a)  cell  count 

to  determine  presence  or  absence  of  pleocytosis,  (6)  Wasser- 

mann  reaction,  (c)  chemical  tests. 

Cell  Count. — Perhaps  of  greatest  help  in  diagnosis  is  the 
cell  count.  The  number  of  cells  per  cubic  millimeter  of 
spinal  fluid  varies  considerably  both  in  health  and  disease, 
and  there  is  no  definite  point  of  demarkation  between  the 
two.  jMost  pathologists  consider  any  number  under  5  as 
a  negative  finding,  between  5  and  8  as  doubtful,  and  over  8 
as  positive. 

Where  the  clinical  data  would  lead  the  physician  to 
expect  a  positive  finding  w^hile  the  actual  finding  is  doubtful  or 
even  negative,  the  lumbar  puncture  may  be  repeated  at  the 
end  of  ten  days.  Either  on  first  or  second  examination  almost 
all  cases  of  general  paralysis  and  cerebral  syphilis  furnish  a 
positive  finding;  other  psychoses  furnish,  on  the  contrary, 
almost  invariably  a  negative  one. 

Wassermann  Reaction. — ^The  Wassermann  reaction  has 
become  an  important  aid,  in  some  cases  an  indispensable  one, 
in  psychiatric  diagnosis.  It  may  be  applied  either  to  the 
blood  or  the  cerebro-spinal  fluid,  or  both,  and  may  be  of 
assistance  (a)  in  differentiating  psychoses  of  syphilitic  nature 
from  others,  (6)  to  some  extent  in  differentiating  general 
paralysis  from  cerebral  syphihs  and  from  cerebral  arteri- 
osclerosis of  syphilitic  origin,  and  (c)  in  judging  the  effect 
of  anti-syphilitic  treatment. 

Chemical  Tests. — The  chemical  tests  most  widely  used  are 
Lange's  colloidal  gold  test,  Noguchi's  butyric  acid  test,  the 
Ross-Jones  ammonium  sulphate  test  and  Pandy's  phenol  test. 
Their  principal  object  is  to  determine  the  presence  or  absence 
of  excess  of  certain  protein  substances  in  the  cerebro-spinal 

^  See  Minet  and  Lavoit.  La  mort  suite  de  pondion  lombaire.  L'Echo 
Medical  du  Nord,  Apr.  25,  1909. 


90  THE  PRACTICE  OF  PSYCHIATRY 

fluid.  They  serve  to  differentiate  general  paralysis,  cerebral 
syphilis,  and  other  conditions  associated  with  inflammatory 
changes  in  the  central  nervous  system  from  conditions, 
organic  or  functional,  which  are  not  associated  with  such 
changes. 

Intelligence  Tests. — The  importance  of  ascertaining  a 
patient's  constitutional  make-up  has  already  been  pointed 
out.  Anomalies  of  make-up  may  be  either  temperamental 
or  intellectual.  For  a  more  accurate  study  of  the  latter  a 
system  of  tests  has  been  devised  by  Binet  and  Simon,  con- 
stituting a  measuring  scale  of  intelligence.  These  tests  have 
been  applied  to  normal  children  of  various  ages  and  have 
thus  been  standardized,  so  that  it  is  now  possible  by  means 
of  them  to  estimate  the  degree  of  mental  development  of  a 
person  in  terms  of  the  age  at  which  such  development 
corresponds  to  the  normal  average.  Thfe  authors  of  these 
tests  have  taken  special  pains  to  eliminate  the  disturbing 
influence  of  education,  having  made  it  their  aim  to  devise  a 
measure  of  natural  mental  capacity  and  not  of  degree  of 
training. 

It  should  be  mentioned  that  many  objections  have 
been  raised  to  the  Binet-Simon  tests,  some  of  which  are 
directed  more  against  their  careless  or  inexpert  use  than 
against  the  principles  on  which  they  are  based.  On  the 
other  hand  some  inherent  weaknesses  have  also  been  dis- 
covered, and  many  modifications  of  the  tests  have  been  de- 
veloped intended  to  improve  them. 

Examination  for  Aphasia. — Cases  of  organic  brain  disease 
with  lesions  involving  the  speech  areas  and  therefore  pre- 
senting symptoms  of  aphasia  require  a  special  method  of 
examination. 

Association   Tests.^ — ^Association    tests   may   be   found 

*  G.  Aschaflfenburg.  Experimentelle  Studien  uber  Assodationen. 
Kraepelin's  Psychologische  Arbeiten,  Vols.  I,  II,  and  IV. — ^^C.  G. 
Jung.  Diagnostische  Associaziationsstudien. — Kent  and  Rosanoff.  A 
Study  of  Association  in  Insanity.  Amer.  Journ.  of  Insanity,  July  and 
Oct.,  1910. 


SPECIAL  DIAGNOSTIC  PROCEDURES  01 

useful  In  studying  disturbances  of  flow  of  thought;  they 
afford  a  means  of  measuring  mental  capacity  somewhat  like 
the  Binet-Simon  tests;  and  they  have  been  used  for  the 
detection  of  subconscious  ideas  or  complexes. 

Other  Tests.i — Many  other  tests,  both  physical  and 
mental,  have  been  more  or  less  thoroughly  standardized 
and  are  available  both  for  clinical  work  and  for  psychiatric 
research. 

The  technique  of  the  more  commonly  employed  special 
diagnostic  procedures  of  the  psychiatric  clinic  will  be  found 
in  Appendices  I  to  VII  in  this  book. 

Medical  Consultations. — The  psychiatrist — especially  one 
whose  practice  is  mainly  institutional — often  finds  himself  in 
a  position  unlike  that  of  other  medical  specialists:  he  is 
responsible  not  only  for  the  diagnosis  and  management  of 
the  nervous  or  mental  disorder  which  he  is  called  upon  to 
treat,  but  also,  by  force  of  peculiar  circumstance,  for  the 
general  welfare  of  the  patient.  If  there  is  any  abnormal 
condition  of  the  eyes,  ears,  nose  or  throat;  if  there  are 
decayed  teeth,  gynecological  trouble,  or  surgical  conditions 
requiring  intervention;  or  if  there  is  anemia,  tuberculosis, 
diabetes,  nephritis,  heart  disease,  intestinal  worms,  or  what 
not,  he  must  see  to  it  that  they  are  brought  to  light  and  their 
nature  exactly  determined,  and  that  they  are  submitted  to 
appropriate  treatment  and  as  far  as  possible  remedied. 

He  cannot,  of  course,  be  proficient  in  all  medical  special- 
ties, but  he  can  and  should  orgaLnize  his  clinical  work  in 
such  a  way  as  to  be  able  to  readily  avail  himself  of  consulta- 
tion with  other  specialists  whenever  necessary. 

^  G.  M.  Whipple.  Manual  of  Mental  and  Physical  Tests.  Second 
edition.  Baltimore,  1915. — Woodworth  and  Wells.  Association  Tests. 
Psychol.  Monographs,  No.  57,  Dec,  1911. — S.  I.  Franz.  Handbook 
of  Mental  Examination  Methods.    Second  Edition,  New  York,  1919. 


CHAPTER  VII 

THE  PRACTICE  OF  PSYCHIATRY  (Continued) 
APPLICATIONS  OF  PSYCHOLOGY  IN  PSYCHIATRY 

Mental  Measurements. — In  psychiatry,  as  in  other 
sciences,  precise  measurement  and  objective  statement 
present  great  advantages.  It  is  desirable  to  express  when- 
ever possible  in  quantitative  terms  the  conduct  and  mental 
status  of  the  patient.  In  this  way  errors  of  personal  inter- 
pretation may  be  avoided  and  reliable  comparisons  made  of 
conditions,  individuals,  and  recorded  observations  of  clini- 
cians. 

Thus,  it  is  quite  as  possible  to  measure  memory  as  it  is  to 
determine  the  pulse.  To  describe  the  former  as  "  rather 
poor  "  is  as  inexcusable  as  to  report  the  latter  as  "  somewhat 
slow."  Even  such  complex  symptoms  as  incoherence,  dis- 
tractibility,  retardation,  dilapidation  of  school  knowledge, 
lend  themselves,  with  certain  limitations,  to  measurement. 

In  the  endeavor  to  express  in  precise  language  the  devia- 
tions of  conduct,  capacity  and  experience,  the  psychiatrist 
finds  frequent  need  for  the  employment  of  technique  and 
materials  elaborated  by  the  psychologist. 

Quantitative  methods  involve  a  considerable  amount  of 
time  and  a  degree  of  professional  skill  which  cannot  be  hastily 
acquired.  In  incompetent  hands  their  results  may  be  given  a 
significance  never  vouched  for  by  their  elaborators,  or  they 
may  fail  to  reveal  the  significant  data  potential  in  them. 
In  slovenly  and  careless  hands  they  may  yield  a  false  impres- 
sion of  accurate  report.     In  the  hands  of  the  unprepared  the 

92 


APPLICATIONS  OF  PSYCHOLOGY  IN  PSYCHIATRY    93 

results  of  their  use  may  often  be  set  forth  as  conclusive 
without  due  regard  to  other  significant  factors.  For  such 
reasons  it  is  desirable  in  practice  for  the  expert  psychologist 
to  be  consulted  in  his  own  field,  just  as  are  the  chemist, 
toxicologist,  and  X-ray  specialist. 

Psychological  measurement  proceeds  by  providing  uni- 
form experimental  situations  or  stimuli,  establishing  by 
preliminary  research  the  normal  or  standard  responses  to 
these  stimuli,  and  so  scoring  the  subject's  reactions  that 
they  may  be  graded  in  terms  of  achievement  or  of  value. 

Normal  Curves  of  Distribution. — Measurements  of  mental 
traits  have  shown  that  individuals  are  distributed,  with 
respect  to  them,  according  to  the  familiar  curve  of  the 
probability  integral.  Human  beings  do  not  fall  into  sharply 
separated  types  or  species,  such  as  the  slow  and  the  fast, 
the  elated  and  the  depressed,  the  normal  and  the  abnormal. 
Instead,  in  any  mental  trait  that  can  be  measured,  the 
human  family  would  be  found  to  constitute  but  a  single 
species,  to  fall  within  the  limits  of  a  normal  curve  of  dis- 
tribution. Such  a  curve  of  frequency  means  that  all  degrees 
of  a  given  trait  will  be  found  to  occur.  Certain  degrees  of 
it,  the  median,  modal  or  average  degree,  occur  most  fre- 
quently. Those  individuals  possessing  this  median  degree 
of  the  trait,  or  deviating  from  it  only  by  a  stated  amount, 
will  constitute  the  typical.  As  one  goes  above  or  below 
this  degree  the  individuals  become  gradually  fewer  and 
fewer. 

In  Fig.  1  are  shown  typical  curves  of  normal  distribution. 
Points  on  the  base  line  or  abscissa  indicate  in  progressive 
order  amount  or  degree  of  a  given  trait.  Points  on  the 
ordinates  indicate  frequency  of  occurrence.  OF  on  both 
curves  represents  the  median  or  average  degree  of  the  trait 
as  well  as  the  fact  of  its  most  frequent  occurrence.  The 
lines  ah  and  cd  are  equally  distant  from  OY,  and  the  area 
obYcd  is  one-half  of  the  total  area  under  the  curve.  The 
measure  aO  or  Od  represents  average  deviation  and  is  tech- 
nically known  as  Probable  Error. 


94 


THE  PRACTICE  OF  PSYCHIATRY 


For  example,  the  average  educated  adult  performance  in 
the  well-known  Tapping  test  is  376  reciprocal  innervations 
in  one  minute.  Half  of  the  individuals  of  this  class  would 
fall  within  37  taps  above  or  below  this  average,  i.e.,  between 
339  and  413  taps.  The  number  37  is,  then,  the  Probable 
Error  of  the  distribution.  Unusual  or  atypical  perform- 
ance would  fall  on  the  base  line  at  a  distance  from  the  median 
greater  than  that  represented  by  the  Probable  Error;  the 
more  unusual  or  atypical  it  is,  the  farther  from  the  median  it 
wHl  fall. 


a    Q  d 


Fig.  1. 


In  a  normal  surface  of  frequency  a  distance  of  one 
Probable  Error  to  one  or  the  other  side  of  the  median  includes 
25%  of  the  total  number  of  cases.  A  distance  of  two 
Probable  Errors  includes  an  additional  17%;  three,  an 
additional  6%,  and  four,  the  remaining  2%,  approximately, 
in  each  case. 

Turning  again  to  the  Tapping  test  as  an  example,  an 
individual  who  should  be  able  to  tap  450  times  in  a  minute 
exceeds  the  average  by  74  taps,  which  is  double  the  Probable 
Error.  He  is  thus  two  Probable  Errors  removed  from  the 
average  in  the  direction  of  superiority.  He  would  be 
excelled  by  only  8%  of  the  group  and  would  himself  be 
number  nine  from  the  top  if  one  hundred  representative 
individuals  were  arranged  in  an  order  of  tapping  ability. 
It  has  thus  been  possible  not  only  to  measure  his  actual 


APPLICATIONS  OF  PSYCHOLOGY  IN  PSYCHIATRY    95 

tapping  rate,  but  also  to  show  what  degree  of  deviation 
from  the  average  the  record  indicates  and  the  frequency  of 
this  capacity. 

Measures  Expressed  in  Terms  of  Maturity. — Another 
important  method  of  measurement  takes  advantage  of  the 
fact  that,  up  to  a  certain  point  in  growth,  achievement  is  a 
function  of  maturity.  The  average  four-year-old  child 
can  repeat  immediately  after  one  hearing,  a  sentence  of 
12  syllables;  the  sLx-year-old,  17  syllables;  the  eight-year- 
old,  19  syllables;  while  at  ten,  thirteen,  and  sixteen  years  the 
memory  spans  are  21,  24  and  28  syllables  respectively.  That 
is  to  say,  irrespective  of  other  conditions,  memory  span  is 
a  function  of  age.  This  is  true  of  most  intellectual  opera- 
tions up  to  a  point  which  ranges  from  11  to  16  years,  accord- 
ing to  the  nature  of  the  process. 

It  is  thus  possible  in  the  case  of,  say,  an  adult  epileptic 
whose  immediate  memory  enables  him  to  repeat  but  17 
syllables,  to  say  that,  although  he  is  chronologically  an  adult, 
his  memory  span  is  only  that  of  an  average  six-year-old 
child.  Other  capacities  or  disabilities  of  a  patient  can 
similarly  be  expressed  ia  terms  of  developmental  units  or 
years  of  growth. 

During  recent  years  rapid  progress  has  been  made  in  the 
standardization  of  capacity  tests  in  terms  of  developmental 
units,  and  new  standardizations  are  from  time  to  time 
reported  and  adopted. 

The  ideal  psychographic  technique  would  call  for  stand- 
ardized tests  for  each  of  those  component  factors  which 
comprise  that  highly  elaborate  complex  we  call  personality. 
Psychological  research  is  still  far  from  realizing  this  goal, 
but  advance  is  being  made  so  rapidly  that  close  specialization 
of  interest  and  cordial  collaboration  of  psychiatrists  and 
psychologists  are  required  in  order  that  satisfactory  progress 
and  application  ia  this  important  field  may  be  assured. 

Intelligence  Scales. — A  notable  step  in  the  science  of 
mental  measurement  was  made  by  Binet  and  Simon  when 
they  attempted,  on  the  basis  of  empirical  investigation,  to 


96  THE  PRACTICE  OF  PSYCHIATRY 

extend  miscellaneous  achievement  scales  from  the  third 
year  up  through  the  later  years  of  childhood  and  youth 
to  maturity.  Accepting  a  year  of  growth  as  a  convenient 
unit  of  division,  experimental  research  enabled  these  investi- 
gators to  establish  at  each  age  level  a  group  of  intelHgence 
tests  which  could  be  accomphshed  by  the  majority  of  chil- 
dren at  that  age,  but  failure  in  which  characterized  the  aver- 
age child  of  younger  ages.  Special  effort  was  made  to  exclude 
such  acts  as  would  depend  on  education  and  training  rather 
than  simple  psycho-physical  growth. 

The  practical  value  of  such  an  intelHgence  scale  was 
readily  appreciated,  and  the  original  scale  soon  underwent, 
at  the  hands  of  numerous  investigators,  such  revisions, 
adaptations,  extensions  and  wider  standardizations  as 
would  render  it  more  reliable  and  comprehensive.  The 
most  widely  used  scale  is  that  known  as  the  Stanford  revision 
formulated  by  Terman  and  his  associates.  Directions  for 
the  use  of  the  Stanford  revision  will  be  found  in  Appendix  V, 
Part  III,  of  this  JManual. 

Other  adaptations,  notably  the  Point  Scale  of  Yerkes 
and  his  collaborators,^  have  been  found  useful  by  many 
workers. 

Such  intelHgence  scales,  and  the  psychographic  methods 
already  discussed,  afford  the  most  reliable  means  of  deter- 
mining intellectual  make-up  and  of  revealing  and  measuring 
mental  deficiency.  In  applying  these  tests  to  cases  of 
psychotic  conditions  it  is,  of  course,  necessaiy  to  guard 
against  mistaking  temporary  disability  of  acute  psychotic 
states  or  acquired  disability  in  states  of  dementia  for  inferi- 
ority of  original  mental  endowment.  In  the  presence  of 
active  psychotic  manifestations  these  tests  are  not  to  be 
applied,  but  one  should  rather  wait  until  the  active  mani- 
festations have  subsided  and  the  patient  is  sufficiently  com- 
posed to  give  full  cooperation. 

Group  Tests. — The  inteHigence  scales  described  above 

1  Yerkes,  Bridges  and  Hardwick.  A  Point  Scale  for  Measuring 
Mental  Ability.     Baltimore,  1915. 


APPLICATIONS  OF  PSYCHOLOGY  IN  PSYCHIATRY    97 

are  used  in  individual  examinations  which  require  the  devo- 
tion of  half  an  hour  to  an  hour  or  more  to  each  subject. 
Many  occasions  arise  in  which  it  is  desirable  to  make  intel- 
lectual ratings  of  large  numbers  of  individuals,  for  which  pur- 
pose the  time-consuming  individual  methods  are  inexpedi- 
ent. Accordingly  for  the  examination  of  army  recruits, 
selection  of  industrial  employees,  classification  of  school 
children,  etc.,  group  tests  have  been  devised.  A  number  of 
standardized  group  tests  will  be  found  described  in  Appendix 
VII,  Part  III,  of  this  Manual. 

Limitations  of  group  tests  are  obvious.  Although  suc- 
cess in  them  may  be  taken  as  reliable  indication  of  the  sub- 
ject's mental  competence,  failure  may  be  due  to  a  great 
variety  of  factors.  Illiteracy,  sensory  defect,  unfamiliarity 
with  the  language  of  the  instructions,  physical  impediment, 
and  psychotic  conditions  may,  in  the  intellectually  com- 
petent, cause  the  showing  to  resemble  that  of  the  mentally 
deficient.  For  these  reasons  subjects  who  fail  in  group 
tests  should  always  be  submitted,  before  decision,  to  in- 
dividual examination.  Group  tests  afford  a  useful  means 
of  indicating  those  most  likely  to  require  closer  individual 
study. 

Association  Tests. — The  tests  described  up  to  this  point 
relate  chiefly  to  the  intellectual  or  cognitive  aspects  of  mental 
life,  and  deal  mainly  with  capacity  to  achieve  in  those 
multifarious  adaptations  which  have  as  their  end  product 
what  we  call  intelligent  conduct.  There  are,  of  course, 
many  other  traits  of  personality  that  have  high  psychiatric 
importance,  and  for  which  methods  of  measurement  are  also 
desirable.  The  relative  strength  of  instincts  and  funda- 
mental trends,  the  affective  make-up,  volitional  character- 
istics, the  focalization  of  effort,  degree  of  accessibility, 
moral  habits,  character  trends,  the  strength  of  determining 
tendencies,  eccentricity  of  values— these  and  other  non- 
cognitive  aspects  of  the  mental  make-up  may  assume  a 
dominant  role  in  the  clinical  picture.  Measurement  in  these 
fields  is  far  less  advanced   than  in   the   determination  of 


98  THE  PRACTICE  OF  PSYCHIATRY 

intelligence  and  capacity,  and  the  more  strictly  cognitive 
functions  such  as  learning,  memory,  perception,  language 
ability,  judgment  and  reasoning.  There  are,  however,  cer- 
tain valuable  quantitative  aids  to  diagnosis  and  descrip- 
tion  which   it  may  often  be  advantageous  to  employ. 

Association  tests  may  be  found  useful  in  studying  dis- 
turbances of  the  flow  of  thought,  and  they  have  been  used  in 
the  technique  of  psychoanalysis.  For  whatever  object 
employed,  it  would  seem  advisable  to  make  use  of  a  stand- 
ardized procedure.  For  this  reason  the  test  developed 
by  Kent  and  Rosanoff  is  recommended.  This  test  has  been 
applied  to  one  thousand  normal  subjects,  and  all  reactions 
thus  obtained  arranged  in  frequency  tables  for  all  stimulus 
words.  The  technique  and  the  necessary  tables  are  given  in 
Appendix  VI,  Part  III,  of  this  Manual. 

In  this  test  normal  subjects  seldom  give  over  10% 
individual  reactions;  psychotic  subjects  very  often  give 
over  25%.  Among  the  individual  reactions  are  contained 
almost  all  those  that  are  of  pathological  significance.  More- 
over, certain  varieties  are  to  be  distinguished  among  the 
individual  reactions  which  are  more  or  less  characteristic 
of  the  various  clinical  types  of  mental  disorder. 

Standards  have  also  been  made  available  for  the  ages  of 
childhood  from  four  to  fifteen  years.  Feeble-mindedness  is 
recognizable  with  the  aid  of  this  test,  and  its  degree  may  be 
roughly  determined  by  reference  to  the  standards  for  normal 
children.  This  test  is  sometimes  capable  of  revealing 
mental  abnormality  where  other  methods  of  examination 
yield  only  negative  results. 

Related  to  the  association  tests  is  the  psychoanalytic 
technique.  The  examiner's  familiarity  with  the  case  will 
suggest  special  stimulus  words.  These  may  be  given 
together  with  those  employed  in  determining  community 
of  ideas,  being  introduced,  say,  after  every  fifth  or  tenth 
one.  In  such  cases  it  is  also  advisable  to  record  in  each  in- 
stance the  reaction  time  in  fifths  of  a  second  by  means  of 
a  stop-watch  or  kymograph.     "  Complexes  "  are  said  to  be 


APPLICATIONS  OF  PSYCHOLOGY  IN  PSYCHIATRY    99 

indicated  either  by  abnormal  types  of  reaction  or  by  length- 
ened reaction  times. 

Experimental  Psycho-pathology  and  Pharmaco-psychol- 
ogy. — Further  ways  in  which  psychological  methods  may  be 
utilized  to  advantage  in  fields  bordering  on  psychiatry  are 
to  be  found  in  the  fields  of  psycho-pathology  and  pharmaco- 
psychology.  Thus  in  recording  the  shifting  phases  of  manic- 
depressive  psychoses  laboratory  technique  may  enable  the 
observer  to  derive  quantitative  measures  of  psychomotor 
excitement,  retardation  and  inhibition.  In  the  study  of  the 
immediate  effects  of  toxic  substances,  which  has  since  the 
early  days  of  experimental  psychology  possessed  a  certain 
interest  for  the  psychiatrist,  stimulation,  depression,  inhibi- 
tion, secondary  reaction,  latent  period  of  action,  and  similar 
facts  may  be  given  definite  and  objective  expression  through 
the  use  of  standardized  capacity  tests  and  other  technical 
devices  of  the  psychological  laboratory.  In  this  way  also 
qualitative  analysis  of  the  incidence  of  the  toxic  influence 
may  be  furthered. 

Educational  Therapeutics. — Training  in  cases  of  mental 
deficiency  and  re-education  in  cases  of  mental  deterioration 
may  be  expected  to  succeed  only  in  so  far  as  they  conform 
to  general  principles  of  educational  psychology,  which 
govern  here  as  well  as  in  all  learning.  The  specificity  of 
habit  formation,  for  instance,  is  fundamental;  and  efforts 
that  do  not  take  this  into  account  are  likely  to  meet  with 
disappointment ;  success  is  attained  only  in  so  far  as  partic- 
ular desirable  habits  are  acquired  and  undesirable  ones  in- 
hibited. The  original  nature  of  man,  which  bulks  so  large 
in  discussions  of  general  educational  procedure,  is  no  less 
important  in  educational  therapeutics. 

Theoretical  Relations. — It  may  not  be  amiss  to  point 
out  in  theoretical  as  well  as  clinical  relations  the  reciprocal 
influence  of  the  concepts  of  psychiatry  and  psychology. 
Differential  psychology,  through  its  measurement  of  the 
degree  and  distribution  of  individual  differences  in  mental 
traits,  has  exerted,  along  with  other  biological   sciences,    a 


100  THE  PRACTICE  OF  PSYCHIATRY 

wholesome  influence  in  modifying  the  older  psychiatric 
concept  of  clinical  entities.  As  regards  the  large  group  of 
constitutional  disorders,  it  is  more  and  more  realized  that 
the  marked  disturbances  encountered  in  institutions  and 
clinics  represent  only  the  extreme  end  of  the  curve  of  dis- 
tribution of  the  symptoms  involved.  The  frequent  resort  in 
recent  years  to  such  diagnoses  as  ''  allied  to  dementia 
praecox  "  and  ''  allied  to  manic-depressive  psychoses  "  marks 
the  professional  recognition  of  the  many  borderline  cases 
intervening  between  the  average  and  the  extreme  deviations. 
The  wholesome  tendency  in  modern  psychiatry,  to  refuse 
to  draw  sharp  lines  of  demarkation  and  to  recognize  many 
of  the  conditions  met  with  in  the  psychiatric  clinic  as  being 
anomalies  of  character  rather  than  diseases  in  the  ordinary 
sense  of  the  word,  is  throughout  supported  by  the  findings 
of  differential  psychology. 

On  the  other  hand,  modern  psychology  has  been  distinctly 
influenced  by  concepts  originating  or  emphasized  in  the  for- 
mulations and  practices  of  psychiatry.  The  emphasis  on 
psychogenic  factors;  the  exposition  of  the  mechanisms  of 
adaptation,  thought,  and  character  formation;  the  insist- 
ence on  the  energic  character  of  mental  life  and  conflicts  and 
resolutions  of  fundamental  trends,  so  conspicuous  in  modern 
psychiatry,  have  had  much  to  do  with  the  advance  of  theo- 
retical or  general  psychology  from  its  old  structural  concepts 
to  its  more  modern  dynamic  point  of  view. 


CHAPTER  VIII 

THE  PRACTICE  OF  PSYCHIATRY  (Continued) 

GENERAL  THERAPEUTIC  INDICATIONS:  INSTITUTION— 
COM  MI  TMEN  T  —  TREA  TMEN  T  OF  EXCI TEMENT, 
SUICIDAL  TENDENCIES,  AND  REFUSAL  OF  FOOD- 
PSYCHOTHERAPY— PAROLE  AND  DISCHARGE— AFTER- 
CARE. 

There  is  no  general  treatment  for  all  mental  affections 
any  more  than  there  is  for  all  affections  of  the  stomach  or 
kidney's.  Certain  therapeutic  indications,  however,  are  of 
such  importance  and  arise  so  often  that  it  will  be  advisable 
to  make  a  general  study  of  them. 

Some  pertain  to  the  surroundings  in  which  patients 
should  be  placed,  others  to  certain  particularly  grave  mani- 
festations: excitement,  suicidal  tendencies,  and  refusal  of 
food. 

Surroundings;  Institution;  Commitment. —  In  most 
psychoses  it  is  necessary  to  secure  for  the  patient  physical 
and  mental  rest  and  to  relieve  him  as  far  as  possible  from  his 
preoccupations,  delusional  or  rational. 

It  is  difficult  to  carry  out  these  indications  in  the  ordi- 
nary conditions  of  life.  The  difficulties  are  of  a  nature  both 
physical  and  mental;  physical,  because  only  few  families  can 
afford  the  expense  involved  in  the  treatment  of  a  psychotic 
patient  at  home;  and  mental,  because  the  relatives,  inexperi- 
enced in  the  treatment  of  mental  diseases,  are  not  likely  to 
carry  out  properly  all  the  orders  of  the  physician,  and  may 
cause  an  aggravation  of  the  patient's  condition  by  yielding 
to  his  caprices,  being  under  the  impression  that  he  must 

101 


102  THE  PRACTICE  OF  PSYCHIATRY 

not  be  contradicted,  and  by  wearying  him  with  attempts 
to  reason  with  him  or  to  divert  his  mind. 

The  removal  to  an  institution  is  therefore  in  most  cases 
inevitable. 

All  psychotic  patients  may  be  grouped  in  two  classes: 
the  inoffensive  and  the  dangerous. 

For  the  first  class  of  cases  the  institution  does  not  pre- 
sent any  particular  features  and  the  admission  of  the  patient 
is  effected  with  no  more  formality  than  that  into  a  general 
hospital. 

The  patients  of  the  second  class  must  be  committed; 
this  must  be  accomplished  under  the  supervision  and 
responsibility  of  a  pubhc  authority,  and  entails  certain 
formalities. 

Of  all  these  formalities  only  one  is  of  interest  to  us  here: 
the  physician's  certificate. 

The  certificate,  intended  to  establish  the  legitimacy 
of  the  commitment,  need  not  contain  any  detailed  obser- 
vations and  does  not  necessarily  involve  a  precise  clinical 
diagnosis.  It  is  of  little  importance  here  whether  the  patient 
does  or  does  not  present  inequality  of  the  pupils  or  abolition 
of  the  patellar  reflexes.  It  is  also  unimportant  whether  he 
suffers  from  mania  or  from  dementia  prsecox,  as  long  as  the 
symptoms  which  he  presents  render  him  a  menace  to  him- 
self, to  others,  or  to  the  public  peace. 

The  indications  for  commitment  are  chiefly  to  be  based 
on  the  dangerous  tendencies  of  the  patient;  a  senile  dement 
who  is  quiet  and  tractable  can  without  any  inconvenience 
be  cared  for  at  home  or  in  a  home  for  the  aged ;  another  who 
is  on  the  contrary  irritable  and  violent  should  be  committed 
without  hesitation. 

In  a  general  way  the  following  symptoms  should  be 
considered  as  indications  for  commitment:  impulsive  ten- 
dencies; suicidal  ideas,  ideas  of  persecution  and  hallucina- 
tions which  bring  about  violent  reactions ;  states  of  dementia 
associated  with  phenomena  of  excitement. 

The  character  and  intensity  of  the  symptoms  should, 


TREATMENT  OF  EXCITEMENT  103 

however,  not  be  the  only  factors  governing  the  action  of  the 
physician.  He  should  also  take  into  account  their  probable 
duration.  If  the  mental  disorder  is  not  likely  to  persist 
for  more  than  several  days  and  has  no  tendency  to  recur 
frequently,  commitment  is  not  justifiable;  such  is  the  case 
in  febrile  deliria. 

Transfer  of  the  Patient  to  the  Institution. — Undoubt- 
edly it  is  the  physician's  duty  to  induce  the  patient  to  go 
to  a  hospital.  Unfortunately  this  is  not  always  easy  or  even 
possible  when  the  question  is  one  of  commitment.  This 
question,  at  times  delicate,  cannot  of  course  have  a  universal 
solution. 

TREATMENT    OF   EXCITEMENT 

Perhaps  the  greatest  progress  in  the  therapeutics  of  mental 
diseases  within  the  past  twenty  years  has  been  in  our  methods 
for  the  treatment  of  excitement. 

By  degrees,  means  of  restraint,  always  useless,  often 
barbarous,  have  disappeared  from  institutions. 

The  methods  employed  to-day  in  combating  excitement 
may  be  grouped  under  four  principal  heads: 

Rest  in  bed; 

Hydrotherapy; 

Isolation; 

Medication. 

Rest  in  Bed.^ — First  used  in  melancholia  (Guislain,' 
Griesinger,  Ball),  rest  in  bed  has  been  only  recently  adopted 
in  the  treatment  of  excitement.  Magnan  has  introduced  its 
use  into  France,  after  having  shown  the  excellence,  of  its 
effects  and  the  relative  facility  of  its  employment. 

Rest  in  bed  presents  the  triple  advantage  of  saving  the 
'patienVs  strength,  calming  excitement,  and  facilitating  super- 
vision. It  is  indicated  in  most  of  the  acute  psychoses  and 
in  the  periods  of  exacerbation  of  chronic  psychoses.     Rest 

1  Pochon.     These  de  Paris,  1899. — Wizel.     Ann.  med.  psrjch.,  1901 
— Serieux  et  Farnarier.    Ann.  med.  psych.,  1900, 


104  THE  PRACTICE  OF  PSYCHIATRY 

in  bed  need  not  necessarily  be  constant  to  be  efficacious, 
except  in  cases  in  which  the  gravity  of  the  general  condition 
requires  it.  It  is  well  to  allow  patients  to  get  up  for  two  or 
three  hours  daily,  using  part  of  the  time  for  outdoor  walks, 
the  duration  of  which  is  to  be  determined  by  the  special 
indications  in  each  case. 

Rest  in  bed  produces  the  best  effects  when  carried  out 
collectively  in  small  dormitories  containing  not  more  than 
ten  beds.  The  example  of  patients  who  have  already  sub- 
mitted to  this  mode  of  treatment  exercises  a  salutary  in- 
fluence upon  newcomers  and  helps  to  induce  them  also  to 
accept  it.  Under  favorable  conditions  two  or  three  days  gen- 
erally suffice  for  even  a  very  excited  patient  to  become 
accustomed  to  staying  in  bed,  and  to  become  calmed  to  a 
certain  extent. 

Though  he  may  still  persist  in  restless  movements,  he 
rarely  leaves  his  bed,  and  when  he  does,  he  will  return  with- 
out difficulty  upon  the  simple  injunction  of  the  nurse. 

Hydrotherapy. — The  cold  douche,  formerly  much  employed 
for  calming  excitement,  has  been  abolished. 

Of  the  various  forms  of  hydrotherapy  two  are  most 
frequently  used :  the  wet  pack  and  the  continuous  warm  bath. 

The  wet  pack  is  applied  by  means  of  a  sheet  soaked  in 
cold  water  and  closely  wrapped  around  the  entire  body. 
Its  duration  varies  from  twenty  minutes  to  several  hours. 
If  kept  on  too  long  it  may  cause  attacks  of  syncope. 

Continuous  warm  haths  are  of  great  service  when  rest 
in  bed  does  not  suffice  to  calm  the  patient.  As  generally 
used,  their  duration  does  not  exceed  five  or  six  hours  daily. 
Some  physicians,  however,  have  obtained  good  results  from 
the  permanent  warm  bath:  the  patient  remains  in  the  bath 
for  days  or  weeks.^  The  bath  tubs  used  for  this  purpose  are 
equipped  with  a  device  for  supplying  a  continuous  flow  of 
water  at  an  even  temperature;  also  with  a  canvas  cradle 
for  the  patient  to  lie  on  and  a  canvas  sheet  for  a  cover. 

1  S6rieux.  Le  traitement  des  etats  d'agitation  par  le  bain  permanent. 
Revue  de  Psychiatrie,  Feb.,  1902. 


TREATMENT  OF  EXCITEMENT  105 

Isolation.^ — Much  opposed  of  late,  isolation  presents,  in 
fact,  certain  inconveniences,  the  greatest  of  which  is  leaving 
the  patient  by  himself  without  constant  supervision;  it  is 
absolutely  contraindicated  in  patients  with  suicidal  ten- 
dencies, and  should  not,  as  a  rule,  be  employed  until  the 
other  measures — rest  in  bed  and  prolonged  baths — have 
been  tried. 

Nocturnal  isolation  consists  in  allowing  the  patient 
to  sleep  in  a  separate  room,  which  should,  of  course,  be 
conveniently  accessible  to  the  attendant;  it  is  of  great 
utility  for  certain  chronic  disturbed  patients.  Many  a 
dement  who  makes  a  great  deal  of  noise  during  the  night  in 
the  dormitory  will  rest  quietly  when  he  is  alone. 

Medication. — We  shall  limit  ourselves  to  the  mention 
of  those  drugs  which  are  most  frequently  used  in  states  of 
excitement,  and  give  several  formulae. 

Opium  and  its  derivatives  are  used  in  the  psychoses; 
extract  of  opium  in  pills,  aqueous  solutions  of  morphine 
for  subcutaneous  injection,  tincture  of  opium,  etc. 

The  danger  of  forming  the  habit  prevents  their  use  in 
cases  requiring  prolonged  treatment. 

Chloral  enjoys  a  merited  reputation.  It  is  administered 
in  solution  by  the  mouth  in  doses  of  from  one  to  two  grams, 
or  per  rectum  in  doses  of  from  two  to  three  grams. 

Chloral  hydrate 1  or  2  grams 

S3TUP  of  currant-berries 30  c.c. 

Water,  enough  to  make 60  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  hydrate 3  grams 

Yolk  of  egg 1 

Milk ■.       120.  c.c. 

To  be  administered  per  rectum,  preceded  by  a  simple  enema. 

1  Mercklin.      Ueber  die  Anwendung  der  Isolierung  bei  der  Behand- 
lung  Geisteskranken.     Allg.  Zeitschr.  f.  Psychiat.,  1903,  No.  6. 


106  THE  PRACTICE  OF  PSYCHIATRY 

Chloral  may  be  combined  with  bromides: 

Chloral  hydrate 1.5  grams 

Potassium  bromide 2  grams 

Syrup  of  currant-berries 30  c.c. 

Water,  enough  to  make 80  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  should  be  absolutely  prohibited  in  cases  of  heart 
disease. 

Bromides  may  also  be  used  alone  in  doses  of  from  two  to 
four  grams. 

Sulphonal,  trional,  and  tetronal  bring  about  calm  and 
prolonged  sleep  in  cases  of  moderate  excitement,  given  in 
doses  of  one  or  two  grams.  They  are  usually  administered 
in  powders  each  containing  one  gram  of  any  one  of  these 
hypnotics.  One  or  two  such  powders,  according  to  the 
case,  is  to  be  administered  in  the  evening  toward  six  o'clock 
the  action  of  these  drugs  being  slow. 

Chloralose,  hypnal,  and  somnal  may  also  be  of  service. 

Chloralose 20  to  60  centigrams 

Given  in  a  powder. 

Hypnal 2  grams 

Chloroform  water 100  c.c. 

Syrup  of  peppermint 30  c.c. 

To  be  administered  in  two  or  three  doses  bv  the  mouth.     (Debove  and 
Gourin.) 

Somnal 2  grams 

Syrup  of  currant-berries 40  c.c. 

Water 20  c.c. 

To  be  administered  like  the  preceding.      (Debove  and  Gourin.) 

Paraldehyde  may  be  given  by  the  mouth,  by  the  rectum, 
or  hypodermically  in  doses  of  from  2  to  5  grams.     It  is  an 


SUICIDAL  TENDENCIES  107 

excellent  hypnotic.  Its  only  inconvenience  is  the  dis- 
agreeable and  persistent  odor  which  it  imparts  to  the  breath. 

Paraldehyde 2  to  5  grams 

Rum 20  c.c. 

Lemon-juice 1.5  c.c. 

Simple  syrup 30  c.c. 

Distilled  water 40  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth.  (Debove  and 
Gourin.) 

Paraldehyde 4  grams 

Yolk  of  egg 1 

Milk 120  c.c. 

To  be  administered  in  one  dose  per  rectum,  preceded  by  a  simple  enema. 

Hyoscine  hydrohromate  or  hydrochlorate  is  a  very  active 
drug  and  must  be  used  with  great  caution.  It  may  be 
administered  in  solution,  in  pills,  or  by  subcutaneous  injec- 
tion. 

Hydrochlorate  of  hyoscine. 0 .  005  gram 

Syrup  of  peppermint 30  c.c. 

Water  enough  to  make 120  c.c. 

A  tablespoonful  every  ten  minutes  until  four  doses  have  been  given. 

Hyoscine  hydrohromate 0 .  02  gram 

Water 20  grams 

For  subcutaneous  injection.  One  ordinary  hypodermic  syringeful 
contains  two  milligrams  of  the  drug.  Half  a  syringeful  is  given  at 
first;  it  is  very  rare  that  the  sedative  effect  is  not  produced  by  a 
whole  syringeful. 


SUICIDAL   TENDENCIES 

Suicide  among  the  insane  is  perhaps  the  greatest  source 
of  anxiety  to  the  practical  psychiatrist.^ 

All  forms  of  mental  alienation  may  give  rise  to  ideas  of 
'  Viallon.     Suicide  etfolie.     Ann.  med.  psych.,  1901. 


108  THE  PRACTICE  OF  PSYCHIATRY 

suicide,  but  the  first  place  from  this  standpoint  belongs  to 
psychoses  of  the  depressed  form  (involutional  melancholia, 
depressed  phase  of  manic-depressive  psychoses,  certain  forms 
of    alcoholism,  etc.). 

Whatever  the  nature  of  the  disease  may  be,  ideas  of 
suicide  may  result : 

(a)  From  an  imperative  hallucination:  a  voice  calls  the 
patient  to  heaven,  orders  him  to  die  in  atonement  for  his 
sins,  etc.; 

(6)  From  a  delusion:  fear  of  death  from  starvation,  of 
being  afflicted  with  an  incurable  disease;  some  patients 
commit  suicide  to  escape  the  imaginary  persecutions  of  their 
enemies; 

(c)  From  an  unconquerable  disgust  for  existence  {trndium 
vitce)  or  from  an  intolerable  psychic  pain; 

{d)  From  a  sudden  impulse  (catatonia) ; 

(e)  From  a  suggestion:  family  suicide,  epidemics  of 
suicide; 

(/)  From  a  fixed  idea,  the  origin  of  which  is  inexplicable. 
Such  is  the  case  reported  by  Ferrari:  An  officer  declared 
on  several  occasions  that  it  was  ridiculous  to  live  beyond 
sixty  years.  On  the  last  day  of  his  sixtieth  year,  after  hav- 
ing passed  a  merry  evening  with  his  friends,  he  announced 
his  intention  of  committing  suicide,  went  into  his  room, 
and  shot  himself  with  a  revolver. 

The  smallest  objects  may  become  in  the  hands  of  patients 
deadly  weapons  which  they  may  turn  against  themselves. 
Magnan  reported  a  case  of  .a  melancholiac  who  perforated 
his  heart  by  means  of  a  needle  measuring  scarcely  3  centi- 
meters in  length.  Some  patients  at  times  resort  to  pro- 
cedures so  horrible  that  their  use  cannot  be  explained  other- 
wise than  by  the  existence  of  marked  anaesthesia;  thus  a 
patient  of  Baillarger's  applied  his  forehead  to  a  red-hot 
plate  of  iron. 

In  institutions,  where  the  patients  are  not  allowed 
to  have  in  their  possession  any  dangerous  instruments, 
the  means  most  frequently  made  use  of  is  hanging,  which 


REFUSAL  OF  FOOD  109 

fact  is  explained  by  the  extreme  simplicity  of  the  pro- 
cedure. 

Together  with  suicide  may  be  classed  the  self-mutilations 
which  patients  frequently  commit. 

Insane  patients  have  been  known  to  cut  off  their  own 
fingers,  lacerate  or  even  cut  off  their  genital  organs  by  means 
of  pieces  of  glass,  open  their  abdomens,  etc. 

The  treatment  of  suicidal  tendencies  is  reduced  to  strict 
and  constant  watching,  which  should  be  instituted  as  soon 
as  the  existence  of  such  tendencies  is  suspected,  and  con- 
tinued for  a  long  time  after  their  apparent  disappearance. 
As  we  have  already  stated  above,  isolation  is  absolutely 
contraindicated.  Keeping  the  patient  in  an  observation 
ward  and  rest  in  bed  during  the  acute  periods  are  very  useful 
measures. 

REFUSAL   OF   FOOD 

Refusal  of  food  ^  may  result  from: 

(a)  Delusions  with  or  without  coexisting  hallucinations: 
fear  of  being  poisoned  or  of  not  being  able  to  digest  the  food; 
hypochondriacal  ideas; 

(6)  The  desire  to  starve  to  death; 

(c)  An  unconquerable  disgust  for  food; 

{d)  Negativism  (catatonia,  general  paralysis). 

Refusal  of  food  may  be  partial  or  complete.  Some 
patients  will  accept  only  certain  kinds  of  food,  often  because 
these  appear  to  them  to  be  the  safest  or  because  "  the 
voices  "  order  them  so.  One  patient  lived  solely  on  eggs, 
the  shell  seeming  to  him  to  be  the  only  impenetrable  barrier 
to  the  mysterious  agencies  used  by  his  persecutors.  One 
precocious  dement  would  take  no  nourishment  other  than 
stale  bread  because  a  voice  from  heaven  commanded  him 
to  do  penance  by  fasting. 

It  may  be  also  absolute  or  relative.     Often  with  a  little 

1  Pfister.  Die  Abstinenz  der  Geisteskranken  und  ihre  Behandlung. 
Freiburg,  1899. 


110  THE  PRACTICE  OF  PSYCHIATRY 

perseverance  one  may  persuade  a  melancholiac  to  accept 
a  sufficient  quantitity  of  nourishment  in  a  convenient  form. 
Some  catatonics  refuse  what  they  have  been  offered  and 
several  minutes  later  devour  their  neighbor's  meal  without 
there  being  any  delusion  to  explain  their  conduct.  Others 
refuse  to  eat,  but  when  food  is  placed  in  their  mouth  they 
swallow  it  without  trouble.  Many  even  submit  with  the 
best  grace  to  being  fed  with  a  spoon  or  with  a  feeding  cup. 

When  refusal  of  food  threatens  to  have  a  bad  effect 
upon  the  health  of  the  patient,  as  is  shown  by  loss  of  weight 
determined  by  regular  weighings,  one  must  resort  to  forced 
feeding  or  ''  tube-feeding." 

Tube-feeding  may  be  accomplished  in  two  ways:  by 
the  mouth  and  by  the  nose. 

Tube-feeding  by  the  mouth  is  the  less  painful  and  less 
dangerous  procedure  for  the  patient  as  well  as  the  more 
convenient  one  for  the  physician. 

The  necessary  instruments  are  a  mouth-gag,  a  stomach- 
tube,  and  a  funnel  of  glass  or  rubber. 

The  operation  itself  is  performed  in  four  stages: 

(1)  Opening  the  mouth; 

(2)  Introducing  the  tube  into  the  stomach; 

(3)  Attaching  the  funnel  to  the  tube  and  ascertaining 
the  proper  penetration  of  the  tube  into  the  stomach; 

(4)  Introducing  the  liquid  food. 

The  first  stage  presents  several  difficulties  due  to  the 
resistance  of  the  patient,  which  is  sometimes  very  great. 
However,  by  dint  of  patience  and  by  taking  advantage  of 
little  interstices  between  the  jaws  it  is  usually  possible  to 
accomplish  this. 

The  introduction  of  the  tube  is  usually  easy.  The  end 
entering  the  pharynx  sets  up  reflexly  the  movements  of 
deglutition,  so  that  the  instrument  of  itself  enters  the  oesoph- 
agus.    A  gentle  push  suffices  to  make  it  enter  the  stomach. 

Although  the  large  size  of  the  tube  renders  a  false  passage 
almost  impossible,  the  purpose  of  the  third  stage  is  to  ascer- 
tain that  the  tube  is  well  in  place  and  has  not  entered  the 


REFUSAL  OF  FOOD  111 

trachea.  Two  procedures  are  used  to  make  sure  of  this: 
auscultation  at  the  opening  of  the  funnel  and  introduction 
into  the  tube  of  several  drops  of  pure  water.  If  the  noise 
produced  by  the  gases  of  the  stomach  is  heard,  and  if  the 
water  runs  down  freely,  the  tube  is  in  place  and  is  not  ob- 
structed. Otherwise  the  tube  must  be  withdrawn  and 
cleaned  and  the  operation  recommenced. 

The  liquid  nourishment  should  always  be  introduced  at  a 
low  pressure.  Its  composition  may  vary  according  to  in- 
dividual cases.  Milk,  eggs,  beef-juice,  peptones,  or  vege- 
table soups  usually  constitute  the  basis. 

Tube-feeding  through  the  nasal  passages  presents  several 
inconveniences: 

(1)  It  is  painful; 

(2)  It  often  causes  irritation  and  inflammation  of  the 
nasal  mucosa; 

(3)  The  small  size  of  the  tube  renders  its  penetration 
into  the  larynx  liable  to  occur,  and  does  not  allow  the  use 
of  any  but  perfectly  liquid  food. 

This  method  of  feeding  should,  therefore,  not  be  resorted 
to  except  in  special  cases,  such  as  those  of  buccal  affections 
interfering  with  the  introduction  of  the  tube  by  the  mouth. 
In  such  cases  a  properly  sterilized  nasal  tube  or  large- 
sized  catheter  is  used;  its  end  is  lubricated  with  sterilized 
vaseline,  and  the  operation  is  then  accomplished  in  three 
stages : 

1.  Introduction  of  the  tube  through  the  nasal  fossae; 
this  is  effected  without  difficulty.  No  force  should  be  used, 
one  nasal  fossa  may  be  found  to  be  obstructed  owing  to  a 
deviation  of  the  septum,  a  growth,  or  swelling  from  any  cause : 
the  tube  may  then  be  introduced  through  the  other  nostril. 

2.  Passing  the  end  of  the  tube  through  the  pharynx. 
This  is  a  most  dehcate  procedure.  Owing  to  reflex  con- 
tractions or  to  voluntary  efforts  on  the  part  of  the  patient 
the  tube  is  very  apt  to  become  coiled  up  in  the  throat, 
eventually  to  be  expelled  by  way  of  the  mouth;  it  must 
then  be  withdrawn  and  the  operation  recommenced.     This 


112  THE  PRACTICE  OF  PSYCHIATRY 

can,  in  a  measure,  be  prevented:  as  the  end  of  the  tube 
enters  the  pharjaix  a  Httle  water  may  be  poured  either  into 
the  funnel  or  into  the  patient's  mouth;  this  starts  up  move- 
ments of  deglutition  by  which  the  end  of  the  tube  is  directed 
into  the  oesophagus.  As  stated  above,  the  tube  may  enter 
the  larynx  and  trachea:  as  soon  as  that  happens  all  groaning 
and  talking  stops  and  with  each  respiratory  act  air  rushes 
in  and  out  of  the  tube  with  a  sucking  and  blowing  noise; 
the  tube  must  then  be  partly  withdrawn,  until  the  end  is 
released  from  the  larynx.  This  is  not  so  apt  to  occur  if  the 
patient's  head  is  raised  by  two  pillows:  in  that  position  the 
direction  of  the  pharynx  is  more  nearly  in  line  with  that  of 
the  oesophagus,  whereas  when  the  head  is  hyper-extended 
the  direction  of  the  pharynx  is  more  nearly  in  line  with  that 
of  the  larynx  and  trachea;  even  the  voluntary  act  of  swal- 
lowing is,  in  this  latter  position,  as  everyone  knows,  difficult. 

3.  Descent  of  the  tube  down  the  oesophagus  and  its 
penetration  into  the  stomach.  The  small  size  of  the  tube 
renders  it  liable  to  be  expelled  by  an  effort  of  vomiting. 
This  does  not  happen  with  a  stomach  tube  such  as  is  used 
in  tube-feeding  by  the  mouth.  By  using  a  tube  which  is 
sufficiently  stiff  this  can  usually  be  prevented. 

Not  infrequently  after  tube-feeding  the  patient  rejects 
the  contents  of  the  stomach  either  spontaneously  or  by  a 
voluntary  effort.  This  may  often  be  prevented  by  throwing 
a  few  drops  of  water  in  his  face.  In  cases  of  obstinate 
vomiting  the  irritability  of  the  stomach  mucosa  may  be 
diminished  by  introducing  with  the  liquid  food  several  drops 
of  a  solution  of  cocaine. 

It  may  be  useful  to  precede  the  feeding  by  lavage  of  the 
stomach. 

PSYCHOTHERAPY 

Psychotherapy  is  the  use  of  psychic  factors  in  the  treat- 
ment of  disease. 

An  essential  element  of  psychotherapy  is  suggestion. 
Its  successful  practice  is  dependent  on  the  nature  of  the  dis- 


PSYCHOTHERAPY  113 

order,  the  attitude  of  the  patient,  and  the  personaHty  of  the 
physician. 

•  The  psychoneuroses  are  most  amenable  to  psychic 
treatment.  The  graver  psychoses  are  much  less  readily 
influenced. 

The  patient  must  have  full  confidence  in  the  physician 
and  in  his  methods.  "  The  nervous  patient  is  on  the  path  to 
recovery  as  soon  as  he  has  the  conviction  that  he  is  going 
to  be  cured ;  he  is  cured  on  the  day  when  he  believes  himself 
to  be  cured."  ^ 

It  follows  that  the  physician  must  be  able  to  inspire 
respect  and  trust.  According  to  Griesinger  ^  he  must  have 
"  a  kind  disposition,  great  patience,  self-possession,  particular 
freedom  from  prejudice,  an  understanding  of  human  nature 
resulting  from  an  abundant  knowledge  of  the  world,  adroit- 
ness in  conversation,  and  a  special  love  of  his  calling." 

As  to  the  manner  of  employing  suggestion  the  indica- 
tions must  be  sought  in  the  individual  case.  In  some  cases, 
the  patient's  faith  being  strong,  a  mere  statement  that  the 
symptoms  are  quickly  disappearing  may  be  sufficient.  In 
other  cases  "  rational  "  suggestion  with  an  explanation  of 
the  cause  of  the  symptoms  and  of  the  best  means  of  com- 
bating them  is  more  effective.  "  There  is  a  great  difference 
in  mentality  between  the  man  who  is  content  with  a  state- 
ment, who  allows  himself  to  be  under  the  influence  of  the 
personality  of  a  healer,  and  the  man  who  acquires  confidence 
by  the  clear  exposition  of  the  reasons  to  believe."  ^  In  still 
other  cases  hypnotic  suggestion  affords  good  results. 

The  following  practical  advice,  evidently  borne  of  abun- 
dant experience,  is  given  by  Dercum: 

"  The  physician  should  not  be  too  aggressive  with  his  suggestions, 
especially  in  the  beginning.  Indeed,  his  attitude  should  be  that  of 
accepting  the  illness  and  symptoms  of  the  patient  as  a  matter  of  course. 

^  Paul    Dubois.     The    Psychic     Treatment    of    Nervous    Disorders. 
English  translation  by  Jelliffe  and  White.     New  York,  1905.     P.  210. 
2  Quoted    by    Kraepelin.     Psychiatric.     Seventh    edition.     Vol.    I. 
5  Paul  Dubois.     Loc.  cit.,  p.  227. 


114  THE  PRACTICE  OF  PSYCHIATRY 

The  mere  institution  of  rest  and  the  various  physiological  procedures, 
is  a  proof  to  the  patient  of  the  sincerity  of  the  physician.  It  is  only 
after  the  treatment  has  been  established  and  has  been  under  way  for 
some  time  that  the  physician  should  begin  a  really  serious  psycho- 
therapy. He  should  never  be  in  a  hurry  to  begin.  The  mistake  may 
be  beyond  remedy,  at  least,  so  far  as  he,  individually,  is  concerned. 
Time  must  be  allowed  for  the  patient  to  '  settle  down,'  i.e.,  to  adapt 
herself  to  her  new  environilient,  her  nurse  and  her  physician.  Very 
soon  the  luxuriousness  and  exquisite  physical  comfort  of  a  properly 
instituted  rest  treatment  makes  its  impression  upon  the  patient.  As 
the  days  go  by,  the  physician  and  the  patient  gradually  become  better 
acquainted.  The  nurse,  too,  learns  the  little  personal  peculiarities 
of  her  patient,  all  of  which  she  faithfully  communicates  to  the  ph3fsician. 
Very  soon  opportunities  occur  for  more  lengthy  conversations,  and  the 
physician  being  now  thoroughly  en  rapport  with  his  patient  and  having 
fully  gained  her  confidence,  can  venture  to  make  free  use  of  suggestion. 
Indirect  suggestion,  we  will  say,  has  been  employed  from  the  begin- 
ning, but  direct  suggestion,  explanatory  and  logical  in  form,  can  now 
be  employed  with  great  effectiveness.  Sometimes  the  conversations 
with  the  patient  reveal  the  way  in  which  this  or  that  special  symptom 
arose,  and  this  clue  may  be  of  value  in  its  subsequent  disposal;  the 
physician  may  point  out  the  inadequacy  of  the  cause  alleged  and  at 
the  same  time  '  explain  away  '  the  symptom."  ^ 

Special  mention  should  be  made  of  religious  influences, 
which  are  of  extraordinary  efficacy  in  some  cases.  Cures 
produced  by  pilgrimages  to  shrines  or  by  the  practice  of 
Christian  Science  are  instances  in  point.  Equally  striking 
are  the  cures  of  habits  of  intemperance  produced  by  religious 
conversion  or,  among  good  Catholics,  by  taking  the  pledge 
of  total  abstinence.  In  these,  as  in  other  measures  of  psy- 
chotherapy, the  active  principle  is  suggestion  and  therefore 
the  existence  of  strong  faith  is  a  condition  necessary  for 
success. 

In  cases  of  mental  deterioration  the  object  of  psj^cho- 
therapy  is  re-education,  not  with  the  hope  of  bringing  about 
recovery,  but  with  that  of  training  the  subject  to  do  some 
simple  yet  productive  labor  (basket  weaving,  mat  making, 
chair  caning,  sewing,  farm  labor,  etc.). 

^  F.  X.  Dercum.  Rest,  Suggestion,  and  Other  Therapeutic  Measures 
in  Nervous  and  Mental  Diseases.     Second  edition.     Philadelphia,  1917. 


PSYCHOTHERAPY  115 

Delusional  states  are  notoriously  refractory  to  sugges- 
tion or  reason.  Yet  in  selected  cases,  in  which  the  delusional 
system  is,  so  to  speak,  of  a  parasitic  nature,  not  essentially 
a  function  of  a  vicious  mental  organization,  something  may 
be  accomplished  when  a  favorable  opportunity  presents 
itself  of  demonstrating  to  the  patient  the  incorrectness  of  his 
belief. 

I  shall  quote  from  the  published  autobiography  of  a 
man  who  had  suffered  from  a  severe  and  prolonged  manic- 
depressive  psychosis  from  which  he  subquently  recovered.^ 

This  man  had  developed  a  complex  system  of  delusions 
of  persecution  by  detectives.  Within  the  space  of  a  fraction 
of  a  minute  he  succeeded  in  fully  correcting  all  his  false  ideas 
when  he  found  convincing  proof  that  he  whom  he  had  re- 
garded as  his  brother's  double  and  a  detective  was  indeed 
his  true  brother. 

"  I  dared  not  ask  for  ink,  so  I  wrote  with  a  lead  pencil.  Another 
fellow  patient  in  whom  I  had  confidence,  at  my  request,  addressed 
the  envelope;  but  he  was  not  in  the  secret  of  its  contents.  This  was 
an  added  precaution,  for  I  thought  the  Secret  Service  men  might 
have  found  out  that  I  had  a  detective  of  my  own  and  would  confiscate 
any  letters  addressed  by  him  or  me.  The  next  morning,  my  '  detec- 
tive '  (a  fellow  patient  who  had  the  privilege  of  going  and  coming 
unattended)  mailed  the  letter.  That  letter  I  still  have,  and  I  treasure 
it  as  any  innocent  man  condemned  to  death  would  treasure  a  pardon 
or  reprieve.  It  should  convince  the  reader  that  sometimes  an  insane 
man  can  think  and  write  clearly.  An  exact  copy  of  this — the  most 
important  letter  I  ever  expect  to  be  called  upon  to  write — is  here 
appended: 

August  29,  1902. 
"  Dear  George: 

On  last  Wednesday  morning  a  person  who  claimed  to  be  George 
M.  Beers  of  New  Haven,  Ct.,  clerk  in  the  Director's  Office  of  the 
Sheffield  Scientific  School  and  a  brother  of  mine,  called  to  see  me. 

"  Perhaps  what  he  said  was  true,  but  after  the  events  of  the  last 
two  years  I  find  myself  inclined  to  doubt  the  truth  of  everything  that 
is  told  me.  He  said  that  he  would  come  and  see  me  again  sometime 
next  week,  and  I  am  sending  you  this  letter  in  order  that  you  may 

1  C.  W.  Beers.  A  Mind  that  Found  Itself.  1908.  New  York 
Longmans,  Green  and  Co. 


116  THE  PRACTICE  OF  PSYCHIATRY 

bring  it  with  you  as  a  passport,  provided  you  are  the  one  who  was 
here  on  Wednesday. 

"  If  you  did  not  call  as  stated  please  say  nothing  about  this  letter 
to  anyone,  and  when  your  double  arrives,  I'll  tell  him  what  I  think 
of  him.  Would  send  other  messages,  but  while  things  seem  as  they 
do  at  present  it  is  impossible.  Have  had  some  one  else  address  en- 
velope for  fear  letter  might  be  held  up  on  the  way. 

Yours, 
Clifford,  W.  B. 

"  Though  I  felt  reasonably  confident  that  this  message  would  reach 
my  brother,  I  was  by  no  means  certain.  I  was  sure,  however,  that, 
should  he  receive  it,  under  no  circumstances  would  he  turn  it  over 
to  any  one  hostile  to  myself.  When  I  wrote  the  words:  '  Dear  George,' 
my  feeling  was  much  like  that  of  a  child  who  sends  a  letter  to  Santa 
Claus  after  his  faith  in  the  existence  of  Santa  Claus  has  been  shaken. 
Like  the  skeptical  child,  I  felt  there  was  nothing  to  lose,  but  everything 
to  gain. 

"  The  thought  that  I  might  soon  get  in  touch  with  my  old  world 
did  not  excite  me.  I  had  not  much  faith  anyway  that  I  was  to  re- 
establish former  relations,  and  what  little  faith  I  had  was  almost 
dissipated  on  the  morning  of  August  30,  1902,  when  a  short  message, 
written  on  a  slip  of  paper,  reached  me  by  the  hand  of  an  attendant. 
It  informed  me  that  my  brother  would  call  that  afternoon.  I  thought 
it  a  lie.  I  felt  that  any  brother  of  mine  would  have  taken  the  pains 
to  send  a  letter  in  reply  to  the  first  I  had  written  him  in  over  two 
years.  The  thought  that  there  had  not  been  time  for  him  to  do  so 
and  that  this  message  must  have  arrived  by  telephone  did  not  then 
occur  to  me.  What  I  believed  was  that  my  own  letter  had  been 
confiscated.  I  asked  one  of  the  doctors  to  swear  on  his  honor  that  it 
really  was  my  own  brother  who  was  coming  to  see  me.  He  did  so 
swear,  and  this  may  have  diminished  my  first  doubt  somewhat,  but  not 
much,  for  abnormal  suspicion  robbed  all  men  in  my  sight  of  whatever 
honor  they  may  have  had. 

"  The  thirtieth  of  the  month  was  what  might  be  called  a  perfect 
June  day  in  August.  In  the  afternoon,  as  usual,  the  patients  were 
taken  out  of  doors,  I  among  them.  I  wandered  about  the  lawn,  and 
cast  freqiient  and  expectant  glances  toward  the  gate,  through  which 
I  believed  my  anticipated  visitor  would  soon  pass.  In  less  than  an 
hour  he  appeared.  I  first  caught  sight  of  him  about  three  hundred 
feet  away,  and,  impelled  more  by  curiosity  than  hope,  I  advanced  to 
meet  him.  '  I  wonder  what  the  lie  will  be  this  time,'  was  the  gist  of 
my  thoughts. 

"  The  person  approaching  me  was  indeed  the  counterpart  of  my 
brother  as  I  remembered  him.      Yet  he  was    no  more  my  brother 


PAROLE— AFTER-CARE  117 

than  he  had  been  at  any  time  during  the  preceding  two  years.  He 
was  still  a  detective.  Suca  he  was  when  I  shook  his  hand.  As  soon 
as  that  ceremony  was  over  he  drew  forth  a  leather  pocket-book.  I 
instantly  recognized  it  as  one  I  myself  had  carried  for  several  years 
prior  to  the  time  I  was  taken  ill  in  1900.  It  was  from  this  that  he  took 
my  recent  letter. 

"  '  Here's  my  passport,'  said  he. 

"  '  It's  a  good  thing  you  brought  it/  said  I  coolly,  as  I  glanced  at 
it  and  again  shook  his  hand — this  time  the  hand  of  my  own  brother. 

"  '  Don't  you  want  to  read  it?  '  he  asked. 

"  '  There  is  no  need  of  that,'  was  my  reply.     '  I  am  convinced  .  .  .  ' 

"  This  was  the  culminating  moment  of  my  gradual  readjustment. 
...  In  a  word,  my  mind  had  found  itself." 

The  subject  of  psychotherapy  is  of  too  great  a  magnitude 
to  be  given  full  discussion  here.  The  general  lines  of 
procedure  have  already  been  indicated.  A  special  considera- 
tion of  psychotherapy  in  application  to  the  psychoneuroses 
will  be  found  in  the  chapter  devoted  to  these  conditions 
in  Part  II,  of  this  Manual.  For  fuller  guidance  in  practical 
psychotherapy  the  student  is  referred  to  the  work  of  Dubois.^ 

A  special  system  of  psychotherapy  has  developed  in  recent 
years  out  of  the  labors  of  Freud  and  his  pupils.  A  presenta- 
tion of  this  system  will  be  found  in  the  chapter  on  Psycho- 
analysis. 

PAROLE   AND    DISCHARGE — AFTER-CARE 

A  patient  who  presents  no  dangerous  or  troublesome 
tendencies  and  who  has  improved  sufficiently  to  justify  his 
trying  to  live  outside  again  may  be,  according  to  the  growing 
custom  of  modern  institutions,  paroled  in  the  custody  of 
relatives  or  friends  for  a  period  which  varies  but  which  in 
the  New  York  state  hospital  service  may  be  as  long  as 
twelve  months.  If  during  the  parole  period  his  condition 
requires  a  return  to  the  hospital  no  legal  procedure  for  re- 
commitment is  necessary;  he  may  be  returned  by  his  cus- 
todians or  by  attendants  sent  from  the  hospital.    If  he  gets 

1  Paul  Dubois.  The  Psychic  Treatment  of  Nervous  Disorders.  Eng- 
lish translation  by  Jelliffe  and  White.     New  York,  1905. 


118  THE  PRACTICE  OF  PSYCHIATRY 

along  well  during  the  entire  period  of  his  parole  he  is  auto- 
matically discharged  at  its  expiration. 

No  test,  no  method  of  examination  affords  a  fairer  or 
more  trustworthy  and  practical  means  of  judging  a  patient's 
ability  to  get  along  outside  of  an  institution.  It  is  not 
strange  therefore  that  the  practice  of  paroling  patients  has 
become  common  in  all  institutions.  Thus  on  June  30,  1918, 
the  nimiber  of  patients  out  on  parole  from  the  thirteen  New 
York  state  hospitals  was  1890. 

The  parole  system  may  thus  be  seen  to  constitute  an 
important  extension  of  institutional  activity.  This,  as 
well  as  the  need  of  further  care  even  for  discharged  patients, 
renders  advisable  for  every  institution  or  system  of  institu- 
tions the  organization  of  systematic  after-care. 

When  a  patient  has  recovered  from  his  mental  trouble 
and  has  been  paroled  or  discharged  from  the  hospital  the 
treatment  of  his  case  must  not  be  regarded  as  finished,  for 
there  is  still  to  be  dealt  with  an  extreme  liahility  to  recurrency. 

Of  a  total  of  8700  cases  admitted  to  the  New  York  state 
hospitals  during  the  year  ending  June  30,  1918,  1903  were 
cases  of  readmission.^  That  is  to  say,  that  minute  fraction 
of  the  population  which  consists  of  patients  discharged  from 
state  hospitals  has  contributed  21.9%  of  all  the  admissions. 

To  what  extent  is  recurrency  preventable? 

(1)  In  some  cases  recurrency  must  be  regarded  as  prob- 
ably inevitable,  though  perhaps  it  can  be  staved  off  by 
general  hygienic  measures;  such  are  cases  of  general  paral- 
ysis in  remission  and  some  manic-depressive  psychoses. 

(2)  In  other  cases,  in  which,  in  addition  to  a  strong 
predisposition  to  mental  disturbance,  there  is  a  history  of 
some  removable  exciting  cause  in  the  etiology  of  the  first 
attack,  recurrency  may  often  be  prevented  by  avoidance  of 
re-exposure  to  the  original  exciting  cause.  It  is  true  that  in 
many  of  these  cases  some  cause,  other  than  the  original  excit- 
ing   cause,  may  give  rise  to  recurrency  owing  to  special 

1  Thirtieth  Annual  Report  of  the  N.  Y.  State  Hospital  Commission 
Albany,  1919. 


PAROLE— AFTER-CARE  1 1 9 

vulnerability  of  the  patient's  mental  organization.  Yet  it 
cannot  be  doubted  that  in  a  good  proportion  of  these  cases 
prophylactic  measures  could  prove  very  successful.  Among 
the  common  avoidable  causes  may  be  mentioned:  loss  of 
employment,  overwork,  inanition  and  exposure  due  to 
poverty,  childbirth,  and  neglected  somatic  disease. 

(3)  In  still  other  cases  in  which  the  trouble  is  due  chiefly 
to  some  avoidable  cause,  recurrency  can  he  absolutely  prevented. 
This  is  a  large  group  of  cases  consisting  of  the  alcoholic 
psychoses,  morphinism,  cocainism,  etc. 

The  problem  of  after-care  with  a  view  to  the  prevention 
of  recurrencies  is  being  met  in  most  hospitals  through  out- 
patient clinics  and  social  service  departments. 


CHAPTER  IX 

THE  PRACTICE  OF  PSYCHIATRY  {Continued) 
PSYCHOANALYSIS  ^ 

Mental  phenomena,  like  physical  ones,  arise  not  spon- 
taneously or  at  random,  but  from  adequate  causes  in  accord- 
ance with  natural  law;  i.e.,  here,  as  elsewhere,  applies  the 
doctrine  of  determinism. 

Mental  disorders  present  to  the  student  two  aspects: 
form  and  content.  The  chapters  in  this  Manual  dealing 
with  symptomatology  are  devoted  to  a  consideration  of  forms 
of  disorder.  For  an  understanding  of  the  particular  factors 
at  work  in  a  given  case  and  for  the  more  purposeful  planning 
of  psychotherapy  a  study  of  content  must  also  be  made. 

Such  a  study  must  concern  itself  not  merely  with  the 
patient's  unguided  formulations,  but  with  a  systematic 
probing  for  psychic  factors  many  of  which  have  passed 
beyond  his  present  recollection  or  awareness.  This  is  the 
particular  task  of  psychoanalysis. 

The  Realm  of  the  Unconscious. — One's  field  of  conscious- 
ness is  at  all  times  limited;  in  other  words,  the  number  of 
representations  within  the  scope  of  actual  awareness  at  any 
given  moment  is  small  in  comparison  with  one's  total  mental 
content.  The  readiness  with  which  stored  impressions  can 
be  recalled  varies.     There  are  probably  many   factors  on 

1  A.  A.  Brill.  Psychanalijsis:  Its  Theories  and  Practical  Applica- 
tion.— C.  G.  Jung.  The  Theory  of  Psychoanalysis. — E.  Jones.  Papers 
on  Psychoanalysis. — O.  Pfister.  The  Psychoanalytic  Method.  English 
translation  by  C.  R.  Payne. — S.  E.  Jelliffe.  The  Technique  of  Psy- 
choanalysis. 

120 


PSYCHOANALYSIS  121 

which  this  variation  depends,  but  one  of  these  is  of  special 
interest  for  psychoanalj^sis — the  factor  of  repression. 

Ideas  are  charged  with  affect.  In  cases  in  which  this 
affect  is  of  a  painful  kind  the  ideas  may  be  repressed,  i.e., 
relegated  to  the  realm  of  the  unconscious  by  a  protective 
mechanism. 

That  which  is  in  the  unconscious  is  not  without  influence 
on  behavior.  The  latter  is,  indeed,  for  the  most  part  motiv- 
ated by  unconscious  factors.  Notably  repressed  ideas, 
wishes,  or  ''  complexes  "  influence  behavior,  and  sometimes 
in  such  a  way  as  to  produce  pathological  manifestations, 
either  by  transference  of  affect  energy  from  the  painful  idea 
to  one  assimilable  in  consciousness  (phobias,  obsessions), 
or  by  conversion  into  a  somatic  manifestation  {tremor,  aphonia, 
paralysis) . 

Many  repressed  ideas  or  complexes  are  of  a  sexual  nature. 
Mental  disorders  are  very  often  .manifested  or  produced  by 
sexual  maladjustment,  and  it  is  therefore  incumbent  on  the 
student  of  psychiatry  to  make  careful  study  of  the  subject 
of  sexuality. 

Sexual  Theory  (Freud). — Elements  of  sexuality  are  pres- 
ent from  birth.  "  It  rather  seems  to  us  that  the  child  brings 
into  the  world  germs  of  sensual  activity  and  that  even  while 
taking  nourishment  it  at  the  same  time  also  enjoys  a  sexual 
gratification  which  it  then  seeks  to  again  procure  for  itself 
through  the  familiar  activity  of  thumb-sucking."  "  This 
manifestation  does  not  yet  know  any  sexual  object,  it  is 
auto-erotic  and  its  sexual  aim  is  under  the  control  of  an 
erogenous  zone."  ^  Thumb-sucking  is  but  one  example 
of  pleasurable  excitation  observ^ed  in  infancy.  Almost  any 
part  of  the  skin  or  exposed  mucous  membrane  may  serve  as 
an  erogenous  zone,  especially  the  anal  and  genital  regions: 
"  Children  utilizing  the  erogenous  sensitiveness  of  the  anal 
zone  can  be  recognized  by  their  holding  back  of  fecal  masses 

'  This  and  other  quotations  in  the  section  devoted  to  the  sexual 
theory  are  from  S.  Freud.  Three  Contributions  to  the  Sextial  Theory. 
EngHsh  translation  by  A.  A.  BrUl, 


122  THE  PRACTICE  OF  PSYCHIATRY 

until  through  accumulation  there  result  violent  muscular 
contractions." 

When  the  genital  region  plays  the  part  of  an  erogenous 
zone  infantile  onanism  develops,  consisting  of  rubbing  with 
the  hands  or  closure  of  the  thighs — the  latter  especially  in 
little  girls.  It  should  be  noted  that  the  genital  region 
plays  no  such  part  here  as  it  is  destined  for  in  adult  life,  but 
merely  on  a  par  with  other  infantile  erogenous  zones. 

Around  the  fifth  year  of  life  sets  in  a  period  of  sexual 
latency.  The  infantile  tendencies  are  gradually  repressed 
through  the  development  of  such  psychic  forces  as  loathing, 
shame,  and  moral  or  aesthetic  sense,  partly  in  the  process  of 
bringing  up  and  partly  by  constitutional  determination.  In 
this  period  the  sexual  energy  is  not  lost  but  diverted  toward 
other  aims  by  a  process  which  has  been  termed  sublimation. 

In  later  childhood  sexual  activity  is  very  apt  to  return 
either  in  the  form  of  masturbation  or  a  pollution-like  process. 
"  Most  of  the  so-called  bladder  disturbances  of  this  period 
are  of  a  sexual  nature;  whenever  the  enuresis  nocturna 
does  not  represent  an  epileptic  attack  it  corresponds  to  a 
pollution." 

"It  is  instructive  to  know  that  under  the  influence  of 
seduction  the  child  may  become  polymorphous-perverse  and 
may  be  misled  into  all  sorts  of  transgressions.  This  goes  to 
show  that  it  carries  along  the  adaptation  for  them  in  its 
disposition." 

At  puberty,  as  all  know,  a  radical  transformation  takes 
place.  (1)  The  primacy  of  the  genital  zones  over  other 
erogenous  zones  is  established.  (2)  A  new  phase  of  sexual 
pleasure  appears,  constituting  the  chief  sexual  aim — the 
end-pleasure,  accompanied  by  relief  of  tension;  this  being 
added  to  the  fore-pleasure,  which  gives  rise  to  tension.  It 
is  to  be  borne  in  mind  that  the  latter  alone  characterizes 
infantile  sexuality  and  that  normally  it  persists  in  but  rudi- 
mentary form  in  adult  life.  (3)  In  girls  a  shifting  takes 
place  of  the  leading  zone  of  erogenous  excitability  from  the 
clitoris  to  the  vagina,  accompanied,  in  the  psychic  sphere, 


PSYCHOANALYSIS  123 

by  a  new  wave  of  repression  which  concerns  clitoris 
sexuahty. 

The  developmental  changes  described  above  affect  the 
sexual  aim.  Other  changes  take  place  simultaneously, 
affecting  the  sexual  object.  "  While  the  very  incipient 
sexual  gratifications  are  still  connected  with  the  taking  of 
nourishment,  the  sexual  impulse  has  a  sexual  object  outside 
its  own  body,  in  the  mother's  breast.  This  object  it  loses 
later,  perhaps  at  the  very  time  when  it  becomes  possible 
for  the  child  to  form  a  general  picture  of  the  person  to  whom 
the  organ  granting  him  the  gratification  belongs." 

"  Throughout  the  latency  period  the  child  learns  to  love 
other  persons  who  assist  it  in  its  helplessness  and  gratify 
its  wants;  all  this  follows  the  model  and  is  a  continuation 
of  the  child's  infantile  relations  to  his  wet  nurse." 

"  The  intercourse  between  the  child  and  its  foster  parents 
is  for  the  former  an  inexhaustible  source  of  sexual  excitation 
and  gratification  of  erogenous  zones,  especially  since  the 
parents — or  as  a  rule  the  mother — supplies  the  child  with 
feelings  which  originate  from  her  own  sexual  life;  she  pats 
it,  kisses  it,  and  rocks  it,  plainly  taking  it  as  a  substitute 
for  a  full-valued  sexual  object." 

At  puberty  a  more  or  less  definite  separation  from  the 
sexual  object  of  childhood  normally  takes  place,  largely 
through  the  operation  of  the  incest  barrier  of  the  prevailing 
morality.  "  The  observance  of  this  barrier  is  above  all  a 
demand  of  cultural  society  which  must  guard  against  the 
absorption  by  the  family  of  those  interests  which  it  needs 
for  the  production  of  higher  social  units.  Society,  therefore, 
uses  every  means  to  loosen  those  family  ties  in  every  individ- 
ual, especially  in  the  boy,  which  are  authoritative  in  childhood 
only." 

This  change  and  the  final  finding  of  the  proper  sexual 
object  is  accomplished  gradually.  "  It  is  a  distinct  echo  of 
this  phase  of  development  that  the  first  serious  love  of  the 
young  man  is  often  for  a  mature  woman  and  that  of  the  girl 
for  an  older  man  equipped  with  authority." 


124  THE  PRACTICE  OF  PSYCHIATRY 

Irregularities  of  sex  development  occur  as  a  result  partly 
of  variations  in  innate  tendency  and  partly  of  environmental 
influences  and  happenings.  "  Every  step  on  this  long  road 
of  development  may  become  a  point  of  fixation."  The  fore- 
pleasure  of  infantile  sexuality  may  persist  in  one  form  or 
another  and  take  the  place  of  the  normal  adult  sexual  aim. 
Many  sexual  perversions  "  merely  represent  a  lingering  at  a 
preparatory  act  of  the  sexual  process." 

When  such  infantile  tendencies,  persisting  in  adult  life, 
become  inhibited  through  repression,  their  energy  is  diverted 
either  into  psychoneurotic  symptoms,  or,  by  sublimation, 
into  artistic,  social,  and  intellectual  activities. 

As  regards  the  sexual  object,  too,  "  Many  persons  are 
detained  at  every  station  in  the  course  of  development 
through  which  the  individual  must  pass;  and  accordingly 
there  are  persons  who  never  overcome  the  parental  authority 
and  never,  or  very  imperfectly,  withdraw  their  affection 
from  their  parents.  They  are  mostly  girls,  who,  to  the 
delight  of  their  parents,  retain  their  full  infantile  love  far 
beyond  puberty,  and  it  is  instructive  to  find  that  in  their 
married  life  these  girls  are  incapable  of  fulfilling  their  duties 
to  their  husbands.  They  make  cold  wives  and  remain 
sexually  anaesthetic.  This  shows  that  the  apparently 
non-sexual  love  for  the  parents  and  the  sexual  love  are 
nourished  from  the  same  source,  i.e.,  that  the  first  merely 
corresponds  to  an  infantile  fixation  of  the  libido." 

Psychopathology  of  Everyday  Life.' — The  mental  mech- 
anisms which  underlie  such  commonplace  occurrences  as 
forgetting  names  or  words  and  making  slips  of  speech, 
writing  or  conduct  have  been  investigated  by  the  psycho- 
analytic method.  It  seems  that  "  besides  the  simple  for- 
getting of  proper  names  there  is  another  forgetting  which 
is  motivated  by  repression."  "  To  avoid  the  awakening  of 
pain   through   memory   is   one   of   the   objects  among   the 

1 S.  Freud.  Psychopathology  of  Everyday  Life.  English  edition 
by  A.  A.  Brill.  All  quotations  in  this  section  are  from  this  work, 
except  those  otherwise  specified. 


PSYCHOANALYSIS  125 

motives  of  these  disturbances.  In  general  one  may  distin- 
guish two  principal  cases  of  name-forgetting:  when  the  name 
itself  touches  something  unpleasant,  or  when  it  is  brought 
into  connection  with  other  associations  which  are  influenced 
by  such  effects." 

The  following  passage  is  quoted  by  Ernest  Jones  from 
The  Life  of  Charles  Darwin:  "  I  had,  during  many  years, 
followed  a  golden  rule,  namely,  that  whenever  a  published 
fact,  a  new  observation  or  thought  came  across  me,  which  was 
opposed  to  my  general  results,  to  make  a  memorandum  of 
it  without  fail  and  at  once;  for  I  had  found  by  experience 
that  such  facts  and  thoughts  were  far  more  apt  to  escape 
from  the  memory  than  favorable  ones." 

''  There  are  some  who  are  noted  as  generally  forgetful, 
and  we  excuse  their  lapses  in  the  same  manner  as  we  excuse 
those  who  are  short-sighted  when  they  do  not  greet  us  in 
the  street.  Such  persons  forget  all  small  promises  which  they 
have  made;  they  leave  unexecuted  all  orders  which  they 
have  received;  they  prove  themselves  unreliable  in  little 
things;  and  at  the  same  tune  demand  that  we  shall  not  take 
these  sKght  offenses  amiss— that  is,  they  do  not  want  us  to 
attribute  these  failings  to  personal  characteristics  but  to 
refer  them  to  an  organic  peculiarity.  I  am  not  one  of  these 
people  myself,  and  have  had  no  opportunity  to  analyze  the 
actions  of  such  a  person  in  order  to  discover  from  the  selec- 
tion of  forgetting  the  motive  underlying  the  same.  I  cannot 
forego,  however,  the  conjecture  per  analogiam,  that  here 
the  motive  is  an  unusual  large  amount  of  unavowed  dis- 
regard for  others  w^hich  exploits  the  constitutional  factor 
for  its  purpose." 

Brill  has  observed  that  ''  We  are  more  apt  to  mislay 
letters  containing  bills  than  cheques."  ^ 

Freud  cites  the  following  report  furnished  by  a  young 

engineer:     "  Some   time  ago  I  w^orked  with  many  others 

in  the  laboratorj^  of  the  High  School  on  a  series  of  compUcated 

experiments  on  the  subject  of  elasticity.     It  was  a  work  that 

^^  A.  A.  Brill.     Psychanalysis:  Its  Theories  and  Practical  Application. 


126  THE  PRACTICE  OF  PSYCHIATRY 

we  undertook  of  our  own  volition,  but  it  turned  out  that  it 
took  up  more  of  our  time  than  we  expected.  One  day 
while  going  to  the  laboratory  with  F.,  he  complained  of 
losing  so  much  time,  especially  on  this  day,  when  he  had  so 
many  things  to  do  at  home.  I  could  only  agree  with  him, 
and  he  added  half  jokingly,  alluding  to  an  incident  of  the 
previous  week:  '  Let  us  hope  that  the  machine  will  refuse 
to  work,  so  that  we  can  interrupt  the  experiment  and  go  home 
earlier.'  In  arranging  the  work,  it  happened  that  F.  was 
assigned  to  the  regulation  of  the  pressure  valve,  that  is, 
it  was  his  duty  to  carefully  open  the  valve  and  let  the  fluid 
under  pressure  flow  from  the  accumulator  into  the  cylinder 
of  the  hydrauhc  press.  The  leader  of  the  experiment  stood 
at  the  manometer  and  called  a  loud  '  Stop! '  when  the 
maximum  pressure  was  reached.  At  this  command  F. 
grasped  the  valve  and  turned  it  with  all  his  force — to  the 
left  (all  valves,  without  any  exception,  are  closed  to  the 
right).  This  caused  a  sudden  full  pressure  in  the  accumula- 
tor of  the  press,  and  as  there  was  no  outlet,  the  connecting 
pipe  burst.  This  was  quite  a  trifling  accident  to  the  machine, 
but  enough  to  force  us  to  stop  our  work  for  the  day,  and  go 
home.  It  is  characteristic,  moreover,  that  some  time 
later,  on  discussing  this  occurrence,  my  friend  F.  could  not 
recall  the  remark  that  I  positively  remember  his  having 
made." 

"  These  as  well  as  other  similar  experiences  have  caused 
me  to  think  that  the  actions  executed  unintentionally  must 
inevitably  become  the  source  of  misunderstanding  in  human 
relations."  "  And  this  is,  indeed,  the  punishment  for  the 
inner  dishonesty  to  which  people  grant  expression  under  the 
guise  of  '  forgetting,'  of  erroneous  actions  and  accidental 
emotions,  a  feeling  which  they  would  do  better  to  confess  to 
themselves  and  others  when  they  can  no  longer  control  it." 

''  Chance  or  symptomatic  actions  occurring  in  affairs  of 
married  life  have  often  a  most  serious  significance,  and  could 
lead  those  who  do  not  concern  themselves  with  the  psychol- 
ogy of  the  unconscious  to  a  belief  in  omens.     It  is  not  an 


PSYCHOANALYSIS  127 

auspicious  beginning  if  a  young  woman  loses  her  wedding- 
ring  on  her  wedding-tour,  even  if  it  were  only  mislaid  and 
Goon  found.  I  know  a  woman,  now  divorced,  who  in  the 
management  of  her  business  affairs  frequently  signed  her 
maiden  name  many  years  before  she  actually  resumed  it." 

"  The  common  character  of  the  mildest  as  well  as  the 
severest  cases,  to  which  the  faulty  and  chance  actions  con- 
tribute, lies  in  the  ability  to  refer  the  phenomena  to  unwel- 
come, repressed,  psychic  material,  which,  though  pushed 
away  from  consciousness,  is  nevertheless  not  robbed  of  all 
capacity  to  express  itself." 

"  One  may  possibly  be  disinclined  to  consider  the  class  of 
errors  which  I  have  here  explained  as  very  numerous  or 
particularly  significant.  But  I  leave  it  to  your  consideration 
whether  there  is  no  ground  for  extending  the  same  points 
of  view  also  to  the  more  unportant  errors  of  judgment,  as 
evinced  by  people  in  life  and  science.  Only  for  the  most 
select  and  most  balanced  minds  does  it  seem  possible  to 
guard  the  perceived  picture  of  external  reality  against  the 
distortion  to  which  it  is  otherwise  subjected  in  its  transit 
through  the  psychic  individuality  of  the  one  perceiving  it." 

Interpretation  of  Dreams.^ — Psychoanalytic  experience 
has  shown  that  the  mechanism  of  dreams  is  closely  related 
to  that  of  phobias,  obsessions,  delusions,  and  other  psycho- 
neurotic and  psychotic  symptoms.  Therefore  the  study  of 
dreams  is  important  for  psychiatry. 

Dreams,  regarded  as  a  psychic  process,  present  some  well- 
known  peculiarities.  In  dreams  things  are  sometimes  recalled 
which  are  inaccessible  to  memory  in  the  waking  state. 
One  of  the  sources  of  such  forgotten  material,  recalled  in 
dreams,  is  in  the  events  of  childhood.  In  the  selection  of 
the  reproduced  material  stress  is  laid  in  dreams  not  only  on 
the  most  significant,  but  also  on  trivial  and  indifferent 
reminiscences.  Among  dream  stimuli  are  to  be  mentioned 
sensory  impressions  (noises,  chilling  of  exposed  parts  of  the 

1  S.  Freud,  The  Interpretation  of  Dreams.  English  translation  by 
A.  A.  Brill.     All  quotations  in  this  section  are  from  this  work. 


128  THE  PRACTICE  OF  PSYCPIIATRY 

body,  subjective  sensations),  organic  physical  excitations 
(cardiac,  pulmonary,  digestive,  uro-genital  disturbances 
in  disease  and  in  health) ,  and  psychic  exciting  sources  (events 
of  waking  hours).  Dreams  are  apt  to  be  quickly  forgotten 
on  waking.  Sleeping  dreams  differ  from  day  dreaming  in 
that  their  character  is  hallucinatory  and  not  ideational  and 
in  the  suspension  of  the  criticism  by  which  they  could  be 
distinguished  from  reahty. 

Perhaps  the  ablest  and  most  thorough  investigation  of  the 
subject  of  dreams  has  been  made  by  Freud,  and  he  has  de- 
developed  a  theory  which  endeavors  to  explain  the  above 
and  other  peculiarities.  His  large  experience  has  led  him 
to  the  following  generalization:  "  When  the  work  of  inter- 
pretation has  been  completed  the  dream  may  be  recognized 
as  the  fulfilment  of  a  wish."  By  interpretation,  in  this  con- 
nection, is  meant  the  bringing  to  light,  by  psychoanalytic 
technique,  of  the  latent  content  of  dreams,  the  starting  point 
in  the  process  being  their  manifest  content. 

"  There  are  dreams  which  are  undisguised  wish-fulfil- 
ments. Wherever  a  wish-fulfilment  is  unrecognizable  and 
concealed,  there  must  be  present  a  feeling  of  repulsion 
towards  this  wish,  and  in  consequence  of  this  repulsion  the 
wish  is  unable  to  gain  expression  except  in  a  disfigured  state." 
"  We  should  then  assume- in  each  human  being,  as  the  primary 
cause  of  dream  formation,  two  psychic  forces  (streams, 
systems),  of  which  one  constitutes  the  wish  expressed  by 
the  dream,  while  the  other  acts  as  a  censor  upon  this  dream 
wish,  and  by  means  of  this  censoring  forces  a  distortion  of 
its  expression."  The  above  generalization  has,  accordingly, 
to  be  restated  as  follows:  "The  dream  is  the  (disguised) 
fulfilment  of  a  (suppressed,  repressed)  wish." 

Freud  is  of  the  opinion  that  the  stimulus  for  every  dream 
is-  to  be  found  among  the  experiences  "  upon  which  one 
has  not  yet  slept,"  i.e.,  those  of  the  preceding  day;  but  the 
material  may*  be  selected  from  all  times  of  life.  As  regards 
the  latter  he  states,  in  fact,  that  "  The  deeper  one  goes  in 
the  analysis  of  dreams,  the  more  often  one  is  put  on  the  tracK 


PSYCHOANALYSIS  129 

of  childish  experiences  which  play  the  part  of  dream  sources 
in  the  latent  dream  content."  ''  As  a  rule,  of  course,  a  child- 
hood scene  is  represented  in  the  manifest  dream  content  only 
by  an  allusion,  and  must  be  extricated  from  the  dream  by 
means  of  interpretation." 

Trivial  matters  are  never,  in  the  opinion  of  Freud,  the 
subject  of  dreams:  "  The  dream  never  concerns  itself  with 
trifles;  we  do  not  allow  ourselves  to  be  disturbed  in  our  sleep 
by  matters  of  slight  importance.  Dreams  which  are  appar- 
ently harmless  turn  out  to  be  sinister  if  one  takes  pains  to 
interpret  them."  "  A  displacement — ^let  us  say  of  the  psychic 
accent — has  taken  place,  until  ideas  that  are  at  first  weakly 
charged  with  intensity,  by  taking  over  the  charge '  from 
ideas  which  have  a  stronger  initial  intensity,  reach  a  degree 
of  strength  which  enables  them  to  force  their  way  into 
consciousness.  Such  displacements  do  not  at  all  surprise 
us  when  it  is  a  question  of  the  bestowal  of  affects  or  of  the 
motor  actions  in  general.  The  fact  that  the  woman  who  has 
remained  single  transfers  her  affection  to  animals,  that 
the  bachelor  becomes  a  passionate  collector,  that  the  soldier 
defends  a  scrap  of  colored  cloth,  his  flag,  with  his  life-blood, 
that  in  a  love  affair  a  momentary  clasping  of  hands  brings 
bliss,  or  that  in  Othello  a  lost  handkerchief  causes  a  burst 
of  rage — all  these  are  examples  of  psychic  displacement  which 
seem  unquestionable  to  us." 

"  A  connection  with  what  has  been  recently  experienced 
would  form  a  part  of  the  manifest  content  of  every  dream  and 
a  connection  with  what  has  been  most  remotely  experienced, 
of  its  latent  content."  With  reference  to  somatic  sources  of 
dream  stimulation,  Freud  has  been  led  to  the  opinion  that 
"  The  essential  nature  of  the  dream  is  not  changed  by  this 
addition  of  somatic  material  to  the  psychic  sources  of 
the  dream;  it  remains  the  fulfilment  of  a  wish  without  refer- 
ence to  the  way  in  which  its  expression  is  determined  by  the 
actual  material." 

The  biological  purpose  of  dreams  seems  to  be  to  prevent 
the  interruption  of  sleep  by  disturbing  sensations  or  thoughts 


130  THE  PRACTICE  OF  PSYCHIATRY 

from  whatever  source  they  may  come.  "  The  dream  is 
the  guardian  of  sleep,  not  the  disturber  of  it."  "  Either  the 
mind  does  not  concern  itself  at  all  with  the  causes  of  sensa- 
tions, if  it  is  able  to  do  this  in  spite  of  their  intensity 
and  of  their  significance,  which  is  well  understood  by  it;  or 
it  employs  the  dream  to  deny  these  stimuli;  or  thirdly,  if 
it  is  forced  to  recognize  the  stimulus,  it  seeks  to  find  that  inter- 
pretation of  the  stimulus  which  shall  represent  the  actual 
sensation  as  a  component  part  of  a  situation  which  is  desired 
and  which  is  compatible  with  sleep."  "  The  wish  to  sleep, 
by  which  the  conscious  ego  has  been  suspended  and  which 
along  with  the  dream-censor  contributes  its  share  to  the 
dream,  must  thus  always  be  taken  into  account  as  a  motive 
for  the  formation  of  dreams,  and  every  successful  dream  is  a 
fulfilment  of  this  wish." 

In  some  dreams,  notably  many  typical  ones,  like  that 
of  appearing  undressed  in  public,  falling,  death  of  near 
relatives,  the  dreamer  experiences  embarassment,  fear, 
anxiety,  or  other  painful  emotion  which  would  seemingly  con- 
tradict the  wish-fulfillment  theory.  It  should  be  borne  in 
mind,  however,  that  "  The  wishes  represented  in  the  dream 
as  fulfilled  are  not  always  actual  wishes.  They  may  also  be 
dead,  discarded,  covered,  and  repressed  wishes,  which  we 
must  nevertheless  credit  with  a  sort  of  continuous  existence 
on  account  of  their  reappearance  in  the  dream."  "  The 
more  one  is  occupied  with  the  solution  of  dreams,  the  more 
willing  one  must  become  to  acknowledge  that  the  majority 
of  the  dreams  of  adults  treat  of  sexual  material  and  give 
expression  to  erotic  wishes."  ''  Let  us  recognize  at  once 
that  this  fact  is  not  to  be  wondered  at,  but  that  it  is  in  com- 
plete har^nony  with  the  fundamental  assumptions  of  dream 
explanation.  No  other  impulse  has  had  to  undergo  so  much 
suppression  from  the  time  of  childhood  as  the  sex  impulse 
in  its  numerous  components,  from  no  other  impulse  have 
survived  so  many  and  such  intense  unconscious  wishes,  which 
now  act  in  the  sleeping  state  in  such  a  manner  as  to  produce 
dreams." 


PSYCHOANALYSIS  131 

Freud  is  of  the  opinion  that  dreams  of  nakedness  are  based 
on  recollections  from  earliest  childhood  and  are  an  expression 
of  repressed  exhibitionism:  "  It  may  be  observed  in  the  case 
of  children  ,  .  .  that  being  undressed  has  a  kind  of  intoxi- 
cating effect  upon  them,  instead  of  making  them  ashamed. 
They  laugh,  jump  about,  and  strike  their  bodies;  the 
mother,  or  whoever  is  present,  forbids  them  to  do  this, 
and  says,  '  Fie,  that  is  shameful — you  mustn't  do  that.' 
Children  often  show  exhibitional  cravings;  it  is  hardly 
possible  to  go  through  a  village  in  our  part  of  the  country 
without  meeting  a  two-  or  three-year-old  tot  who  lifts  up 
his  or  her  shirt  before  the  traveller,  perhaps  in  his  honour." 
The  disagreeable  emotion  accompanying  these  dreams  is  the 
manifestation  of  an  intrapsychic  conflict:  "According  to 
our  unconscious  purpose,  exhibition  is  to  be  continued; 
according  to  the  demands  of  the  censor,  it  is  to  be  stopped." 

"  Dreams  of  falling  are  most  frequently  characterized 
by  fear.  Their  interpretation,  when  they  occur  in  women, 
is  subject  to  no  difficulty  because  women  always  accept  the 
symbolic  sense  of  falling,  which  is  a  circumlocution  for  the 
indulgence  of  an  erotic  temptation." 

Referring  to  the  rather  common  dreams  of  the  death  of 
a  near  relative,  Freud  states:  "  The  death  wish  of  the  child 
towards  its  brothers  and  sisters  has  been  explained  by  the 
childish  egotism,  which  causes  the  child  to  regard  its  brothers 
and  sisters  as  competitors."  "  Dreams  of  the  death  of  par- 
ents predominantly  refer  to  that  member  of  the  parental 
couple  which  shares  the  sex  of  the  dreamer,  so  that  the 
man  mostly  dreams  of  the  death  of  his  father,  the  woman 
of  the  death  of  her  mother." 

"  According  to  my  experience,  which  is  now  large,  parents 
play  a  leading  part  in  the  infantile  psychology  of  all  later 
neurotics,  and  falling  in  love  with  one  member  of  the  parental 
couple  and  hatred  of  the  other  help  to  make  up  that  fateful 
sum  of  material  furnished  by  the  psychic  impulses,  which  has 
been  formed  during  the  infantile  period,  and  which  is  of 
such  great  importance  for  the  symptoms  appearing  in  the 


132  THE  PRACTICE  OF  PSYCHIATRY 

later  neurosis.  But  I  do  not  think  that  psychoneurotics 
are  here  sharply  distinguished  from  normal  human  beings, 
in  that  they  are  capable  of  creating  something  absolutely 
new  and  peculiar  to  themselves.  It  is  far  more  probable, 
as  is  shown  also  by  occasional  observation  upon  normal 
children,  that  in  their  loving  or  hostile  wishes  towards  their 
parents  psychoneurotics  only  show  in  exaggerated  form 
feelings  which  are  present  less  distinctly  and  less  intensely 
in  the  minds  of  most  children.  Antiquity  has  furnished  us 
with  legendary  material  to  confirm  this  fact,  and  the  deep 
and  universal  effectiveness  of  these  legends  can  only  be 
explained  by  the  above-mentioned  assumption  in  infantile 
psychology." 

"  I  refer  to  the  legend  of  King  QEdipus  and  the  drama  of 
the  same  name  by  Sophocles.  CEdipus,  the  son  of  Laius, 
king  of  Thebes,  and  of  Jocasta,  is  exposed  while  a  suckling, 
because  an  oracle  has  informed  the  father  that  his  son,  who 
is  still  unborn,  will  be  his  murderer.  He  is  rescued,  and  grows 
up  as  the  king's  son  at  a  foreign  court,  until,  being  uncertain 
about  his  origin,  he  also  consults  the  oracle,  and  is  advised  to 
avoid  his  native  place,  for  he  is  destined  to  become  the 
murderer  of  his  father  and  the  husband  of  his  mother.  On 
the  road  leading  away  from  his  supposed  home  he  meets 
King  Laius  and  strikes  him  dead  in  a  sudden  quarrel.  Then 
he  comes  to  the  gates  of  Thebes,  where  he  solves  the  riddle  of 
the  Sphynx  who  is  barring  the  way,  and  he  is  elected  king 
by  the  Thebans  in  gratitude,  and  is  presented  with  the  hand 
of  Jocasta.  He  reigns  in  peace  and  honour  for  a  long  time, 
and  begets  two  sons  and  two  daughters  upon  his  unknown 
mother,  until  at  last  a  plague  breaks  out  which  causes  the 
Thebans  to  consult  the  oracle  anew.  Here  Sophocles' 
tragedy  begins.  The  messengers  bring  the  advice  that  the 
plague  will  stop  as  soon  as  the  murderer  of  Laius  is  driven 
from  the  country.  But  where  is  he  hidden?  '  Where  are 
they  to  be  found?  How  shall  we  trace  the  perpetrators  of 
so  old  a  crime  where  no  conjecture  leads  to  discovery?  ' 
The  action  of  the  play  now  consists  merely  in  a  revelation, 


PSYCHOANALYSIS  133 

which  is  gradually  completed  and  artfully  delayed — re- 
sembling the  work  of  psychoanalysis — of  the  fact  that  (Edi- 
pus  himself  is  the  murderer  of  Laius,  and  the  son  of  the  dead 
man  and  of  Jocasta.  Gj]dipus,  profoundly  shocked  at  the 
monstrosities  which  he  has  unknowingly  committed,  blinds 
himself  and  leaves  his  native  place.  The  oracle  has  been 
fulfilled." 

"  Perhaps  someone  will  now  object  that,  although  the 
inimical  impulses  of  children  towards  their  brothers  and 
sisters  (or  parent)  may  well  enough  be  admitted,  how  does 
the  childish  disposition  arrive  at  such  a  height  of  wickedness 
as  to  wish  death  to  a  competitor  or  stronger  playmate,  as 
though  all  transgressions  could  be  atoned  for  only  by  the 
death-punishment?  Whoever  talks  in  this  manner  forgets 
that  the  childish  idea  of  '  being  dead  '  has  little  else  but  the 
words  in  common  with  our  own.  The  child  knows  nothing 
of  the  horrors  of  decay,  of  shivering  in  the  cold  grave,  of 
the  terror  of  the  infinite  Nothing,  which  the  grown  up  person, 
as  all  the  myths  concerning  the  Great  Beyond  testify,  finds 
it  so  hard  to  bear  in  his  conception.  Fear  of  death  is  strange 
to  the  child;  therefore  it  plays  with  the  horrible  word  and 
threatens  another  child." 

Symbolism  in  Dreams. — "  When  one  has  become  familiar 
with  the  abundant  use  of  symbolism  for  the  representation  of 
sexual  material  in  dreams,  one  naturally  raises  the  question 
whether  there  are  not  many  of  these  symbols  which  appear 
once  and  for  all  with  a  firmly  established  significance  like  the 
signs  in  stenography;  and  one  is  tempted  to  compile  a  new 
dream-book  according  to  the  cipher  method.  In  this 
connection  it  may  be  remembered  that  this  symbolism  does 
not  belong  peculiarly  tc  the  dream,  but  rather  to  uncon- 
scious thinking,  particularly  that  of  the  masses,  and  it  is  to 
be  found  in  greater  perfection  in  the  folk-lore,  in  the  myths, 
legends,  and  manners  of  speech,  in  the  proverbial  sayings,  and 
in  the  current  witticisms  of  a  nation  than  in  its  dreams." 

"  The  dream  takes  advantage  of  this  symbolism  in  order 
to  give  a  disguised  representation  of  its  latent  thoughts. 


134  THE  PRACTICE  OF  PSYCHIATRY 

Among  the  symbols  which  are  used  in  this  manner  there  are 
of  course  many  which  regularly,  or  almost  regularly,  mean  the 
same  thing.  Only  it  is  necessary  to  keep  in  mind  the  plas- 
ticity of  psychic  material.  Now  and  then  a  sjrmbol  in  the 
dream  content  may  have  to  be  interpreted  not  symbolically, 
but  according  to  its  real  meaning;  at  another  time  the 
dreamer,  owing  to  a  peculiar  set  of  recollections,  may  create 
for  himself  the  right  to  use  anything  whatever  as  a  sexual 
symbol,  though  it  is  not  ordinarily  used  in  that  way.  Nor 
are  the  most  frequently  used  sexual  symbols  unambiguous 
every  time." 

"  After  these  Hmitations  and  reservations  I  may  call 
attention  to  the  following:  Emperor  and  Empress  (King 
and  Queen)  in  most  cases  really  represent  the  parents  of 
the  dreamer;  the  dreamer  himself  or  herseK  is  the  prince  or 
princess.  All  elongated  objects,  sticks,  tree-trunks,  and 
umbrellas  (on  account  of  the  stretching-up  which  might  be 
compared  to  an  erection!)  all  elongated  and  sharp  weapons, 
knives,  daggers,  and  pikes,  are  intended  to  represent  the 
male  member.  A  frequent,  not  very  intelligible,  symbol 
for  the  same  is  a  nail-file  (on  account  of  the  rubbing  and 
scraping?).  Little  cases,  boxes,  caskets,  closets,  and  stoves 
correspond  to  the  female  part.  The  symbolism  of  lock  and 
key  has  been  very  gracefully  employed  by  Uhland  in  his  song 
about  the  '  Graf  en  Eberstein,'  to  make  a  common  smutty 
joke.  The  dream  of  walking  through  a  row  of  rooms  is  a 
brothel  or  harem  dream.  Staircases,  ladders,  and  flights 
of  stairs,  or  climbing  on  these,  either  upwards  or  downwards, 
are  symbohc  representations  of  the  sexual  act.  Smooth 
walls  over  which  one  is  climbing,  fagades  of  houses  upon 
which  one  is  letting  oneself  down,  frequently  under  great 
anxiety,  correspond  to  the  erect  human  body,  and  probably 
repeat  in  the  dream  reminiscences  of  the  upward  climb- 
ing of  little  children  on  their  parents  or  foster  parents. 
'  Smooth '  walls  are  men.  Often  in  a  dream  of  anxiety 
one  is  holding  on  firmly  to  some  projection  from  a  house. 
Tables,  set    tables,  and    boards    are   women,  perhaps  on 


PSYCHOANALYSIS  135 

account  of  the  opposition  which  does  away  with  the 
bodily  contours.  Since  '  bed  and  board  '  (mensa  et  thorus) 
constitute  marriage,  the  former  are  often  put  for  the  latter 
in  the  dream,  and  as  far  as  practicable  the  sexual  presen- 
tation complex  is  transposed  to  the  eating  complex.  Of 
articles  of  dress  the  woman's  hat  may  frequently  be  defi- 
nitely interpreted  as  the  male  genital.  In  dreams  of 
men  one  often  finds  the  cravat  as  a  symbol  for  the  penis; 
this  indeed  is  not  only  because  cravats  hang  down  long, 
and  are  characteristic  of  the  man,  but  also  because  one 
can  select  them  at  pleasure,  a  freedom  which  is  prohibited 
by  nature  in  the  original  of  the  symbol.  Persons  who 
make  use  of  this  symbol  in  the  dream  are  very  extrava- 
gant with  cravats,  and  possess  regular  collections  of  them. 
All  complicated  machines  and  apparatus  in  dream  are  very 
probably  genitals,  in  the  description  of  which  dream  sym- 
bolism shows  itself  to  be  as  tireless  as  the  activity  of  wit. 
Likewise  many  landscapes  in  dreams,  especially  with  bridges 
or  with  wooded  mountains,  can  be  readily  recognized  as 
descriptions  of  the  genitals.  Finally  where  one  finds  incom- 
prehensible neologisms  one  may  think  of  combinations  made 
up  of  components  having  a  sexual  significance.  Children  also 
in  the  dream  often  signify  the  genitals,  as  men  and  women 
are  in  the  habit  of  fondly  referring  to  their  genital  organ 
as  their  '  little  one.'  As  a  very  recent  symbol  of  the  male 
genital  may  be  mentioned  the  flying  machine,  utilization  of 
which  is  justified  by  its  relation  to  flying  as  well  as  occasion- 
ally by  its  form.  To'  play  with  a  little  child  or  to  beat  a 
little  one  is  often  the  dream's  representation  of  onanism." 

Dream  Mechanisms. — In  the  translation  of  dream  thoughts 
into  dream  content  three  principal  mechanisms  are  at  work: 
condensation,  displacement,  and  moulding  for  presentability. 

"  The  first  thing  which  becomes  clear  to  the  investigator 
in  the  comparison  of  the  dream  content  with  the  dream 
thoughts  is  that  a  tremendous  work  of  condensation  has 
taken  place.  The  dream  is  reserved,  paltry,  and  laconic  when 
compared  with  the  range  and  copiousness  of  the  dream 


136  THE  PRACTICE  OF  PSYCHIATRY 

thoughts."  "  Every  element  of  the  dream  content  turns  out 
to  be  over-determined — that  is,  it  enjoys  a  manifold  repres- 
entation in  the  dream  thoughts." 

"  In  the  formation  of  dreams  those  elements  which  are 
emphasized  with  intense  interest  may  be  treated  as  though 
they  were  inferior,  and  other  elements  are  put  in  their 
place  which  certainly  were  inferior  in  the  dream  thoughts." 
"  There  has  taken  place  in  the  formation  of  the  dream  a 
transference  and  displacement  of  the  psychic  intensities  of 
the  individual  elements."  "  The  process  which  we  assume 
here  is  nothing  less  than  the  essential  part  of  dream  activity; 
it  merits  the  designation  of  dream  displacement.  Dream 
displacement  and  dream  condensation  are  the  two  craftsmen 
to  whom  we  may  chiefly  attribute  the  moulding,  of  the 
dream."  '*  We  are  already  acquainted  with  dream  dis- 
figurement; we  have  traced  it  back  to  the  censorship  which 
one  psychic  instance  in  the  psychic  life  exercises  upon  the 
other.  Dream  displacement  is  one  of  the  chief  means  for 
achieving  this  disfigurement."  "  We  may  assume  that 
dream  displacement  is  brought  about  by  the  influence  of  this 
censor,  of  the  endopsychic  repulsion." 

''  A  third  factor,  whose  part  in  the  transformation  of  the 
dream  thoughts  into  the  dream  content  is  not  to  be  con- 
sidered trivial,  is  the  regard  for  presentability  (German: 
Darstellbarkeit)  in  the  peculiar  psychic  material  which  the 
dream  makes  use  of — that  is  fitness  for  representation,  for  the 
most  part  by  means  of  visual  images.  Among  the  various 
subordinate  ideas  associated  with  the  essential  dream 
thoughts,  that  one  will  be  preferred  which  permits  of  a  visual 
representation,  and  the  dream  activity  does  not  hesitate 
promptly  to  recast  the  inflexible  thought  into  another 
verbal  form,  even  if  it  is  the  more  unusual  one,  as  long  as  this 
form  makes  dramatization  possible,  and  thus  puts  an  end 
to  the  psychological  distress  caused  by  cramped  thinking." 

"  It  has  been  my  experience — and  to  this  I  have  found 
no  exception — that  every  dream  treats  of  one's  own  person. 
Dreams  are   absolutely  egotistic.     In  cases  where  not  my 


PSYCHOANALYSIS  137 

ego,  but  only  a  strange  person  occurs  in  the  dream  content, 
I  may  safely  assume  that  my  ego  is  concealed  behind  that 
person  b}-  means  of  identification." 

Freud's  observations  concerning  the  affects  in  dreams 
are  of  great  interest:  "  The  fact  that  in  dreams  the  presenta- 
tion content  does  not  entail  the  affective  influence  which  we 
should  expect  as  necessary  in  waking  thought  has  always 
caused  astonishment."  ''  I  am  in  a  horrible,  dangerous,  or 
disgusting  situation  in  the  dream,  but  I  feel  nothing  of  fear 
or  aversion;  on  the  other  hand,  I  am  sometimes  terrified  at 
harmless  things  and  glad  at  childish  ones.  This  enigma 
of  the  dream  disappears  more  suddenly  and  more  completely 
than  perhaps  any  other  of  the  dream  problems,  if  we  pass 
from  the  manifest  to  the  latent  content.  We  shall  no  longer 
be  concerned  to  explain  it,  for  it  will  no  longer  exist.  Analysis 
teaches  us  that  presentation  contents  have  undergone  dis- 
placements and  substitutions,  while  affects  have  remained 
unchanged." 

Two  Kinds  of  Thinking:  Realistic  and  Autistic— No 
deep  insight  into  mental  mechanisms  is  possible  without 
taking  cognizance  of  the  fact  of  two  kinds  of  thinking: 
one  variously  designated  logical,  directed,  or  realistic,  the 
other  dream,  'phantasy,  or  autistic  thinking.  "  The  first, 
working  for  communication  with  speech  elements,  is  trouble- 
some 9.nd  exhausting;  the  latter,  on  the  contrary,  goes  on 
without  trouble,  working  spontaneously,  so  to  speak,  with 
reminiscences.  The  first  creates  innovations,  adaptations, 
imitates  reality  and  seeks  to  act  upon  it.  The  latter,  on 
the  contrary,  turns  away  from  reality,  sets  free  subjective 
wishes,  and  is,  in  regard  to  adaptation,  wholly  unpro- 
ductive." 1 

"  In  general,  a  tendency  to  realistic,  '  logical,'  'common- 
sense  '  thinking  grows  in  us  by  reason  of  its  service  in  meeting 
our  situations  favorably  and  wholesomely.  Just  as  useful 
patterns  of  behavior  tend  to  be  perpetuated,  and  harmful 

1 C.  G.  Jung.  Psychology  of  the  Unconscious.  Englisli  Transla- 
tion by  Beatrice  M.  Hinkle.     New  York,  1916. 


138  THE  PRACTICE  OF  PSYCHIATRY 

ones  to  disappear  by  selection,  so  have  the  modes  of  thought 
that  are  more  useful  tended  more  and  more  to  order  our 
important  actions.  Almost  the  entire  thinking  of  primitive 
humanity  was  governed  by  indiscriminate,  simply  associative 
modes  of  thought,  not  yet  subjected  to  the  selective  test  of 
'  working  '  or  failure.  Autistic  thinking  in  relation  to  the 
sphere  of  voluntary  conduct  is  therefore  very  prominent  in 
them.  Such  thinking  appears  in  the  foreground  of  mental 
disease  as  we  see  it  to-day.  But  in  normal  persons,  autistic 
thinking  is  gradually  being  relegated  to  less  essential  func- 
tions, like  dreaming,  wit,  and  forms  of  mental  recreation. 
In  the  mentally  healthier  persons,  this  relegation  and  selec- 
tion is  the  more  complete.  Realistic  and  directive  thinking 
has  been  more  and  more  selected  for  survival."  ^ 

"  The  element  of  the  dream  thoughts  which  I  have  in 
mind,  I  am  in  the  habit  of  designating  as  a  '  phantasy  ' ; 
perhaps  I  shall  avoid  misunderstanding  if  I  immediately 
adduce  the  day  dream  of  waking  life  as  an  analogy."  ''  A 
more  thorough  examination  into  the  character  of  these 
day  phantasies  shows  with  what  good  reason  the  same 
name  has  been  given  to  these  formations  as  to  the  products 
of  our  nocturnal  thoughts — dreams."  "  Like  dreams,  they 
are  fulfilments  of  wishes;  like  dreams,  a  good  part  of  them 
are  based  upon  the  impressions  of  childish  experiences; 
like  dreams  their  creations  enjoy  a  certain  amount  of  indul- 
gence from  the  censor."  The  sleeping  dream,  however,  is 
distinguished  from  the  day  dream  in  that  "  the  presenta- 
tion content  is  not  thought,  but  changed  into  perceptible 
images  to  which  we  give  credence  and  which  we  believe  we 
experience."  ^ 

"  The  boundary  line  between  rational  and  autistic  specu- 
lations cannot  be  laid  down  by  human  intellect.  What  is 
inconceivable  to-day  may  to-morrow  become  fact;  what 
is   firmly   believed   to-day   may   to-morrow   become   false. 

1  F.  L.  Wells.     Mental  Adjustments.     New  York,  1917. 

2  S.  Freud.  The  Interpretation  of  Dreams.  English  translation  by 
A.  A.  BrUl.     New  York,  1916. 


PSYCHOANALYSIS  139 

Therefore  a  humanity  without  autistic  thinking  could  not 
have  been  developed.  But  autistic  thinking  being  once 
there,  it  will  be  used,  whensoever  convenient,  whether  useful 
or  not.  Now  conceptions  are  pleasant  or  unpleasant  just 
as  well  as  outer  experiences.  One  can  therefore  give  pleasure 
to  oneself  by  dwelling  on  pleasant  ideas.  But  the  animal 
organism  is  from  phylogenetically  ancient  times  adapted  to 
seek  pleasure  and  to  avoid  pain.  In  the  outer  world  the 
pleasure-  and  pain-provoking  events  are  such  that  this 
reaction  upon  them  corresponds  in  general  to  our  needs. 
But  in  pure  imagination  at  once  a  new  field  of  unlimited 
possibilities  unfolds  itself.  Therein  is  the  danger  for  man  and 
at  the  same  time  his  advantage  over  the  brutes.  The  health 
of  the  individual  and  of  nations  demands  a  balanced  propor- 
tion of  autistic  and  realistic  function.  The  realistic  must 
control  the  autistic.  But  the  autistic  contains  most  of  our 
ideals.  Let  us  take  care  to  keep  them  on  the  same  level  as 
our  technical  progress  and  not  to  misuse  them  to  harass  and 
to  destroy  our  neighbors."  ^ 

Technique  of  Psychoanalysis. — Psychoanalysis  may  be 
undertaken  either  for  the  purpose  of  gaining  insight  into 
underlying  mental  mechanisms  of  normal  or  abnormal 
conduct,  or  for  a  therapeutic  purpose.  If  for  the  latter,  it 
is  important  to  bear  in  mind  that  not  all  cases  can  be  materi- 
ally benefited  by  this  method  of  treatment.  Psychoanalysis 
should  not  be  attempted  with  patients  of  low  cultural  status, 
or  in  cases  of  marked  mental  deficiency,  psychoses  of  estab- 
lished chronicity,  or  those  arising  on  an  organic  basis.  Old 
age,  grave  character  defects,  and  unwillingness  to  be  cured 
are  among  other  conditions  constituting  obstacles  to  success- 
ful psychoanalytic  treatment.  Psychoneuroses  and  mild  or 
remittent  psychoses,  occurring  in  intelligent,  educated,  and 
sincere  persons  are  most  hopeful  as  regards  results  to  be 
derived  from  psychoanalytic  treatment. 

Inasmuch  as  psychoanalysis  is  undertaken  in  cases  in 

1  E.  Bleuler.  Autistic  Thinking.  Amer.  Journ.  of  Insanity,  Special 
Number,  Vol.  LXIX,  1913. 


140  THE  PRACTICE  OF  PSYCHIATRY 

which  symptoms  are  assumed  to  be  actuated  by  complexes 
that  are  submerged  in  the  region  of  the  unconscious  by 
reason  of  being  charged  with  painful  affect,  the  physician 
must  be  prepared  to  meet  with  more  or  less  determined 
resistance  to  his  probing.  To  overcome  this  resistance  it 
is  necessary,  while  becoming  acquainted  with  the  patient, 
in  the  course  of  history  taking  and  physical  examination,  and 
before  the  work  of  psychoanalysis  proper  is  begun,  to  inspire 
the  patient  with  friendhness,  respect,  confidence,  hopeful- 
ness, and,  above  all,  a  certain  intimacy  which  might  be  likened 
to  that  of,  say,  parent  and  child. 

Some  such  relationship  between  physician  and  patient  has 
always  been  instinctively  understood  to  be  desirable  even 
where  it  is  merely  a  question  of  the  patient  submitting  to  a 
surgical  procedure,  a  dietetic  regime,  or  a  course  of  medi- 
cation. In  cases  requiring  psychoanalysis  it  is  an  indis- 
pensable condition.  In  older  psychotherapy  it  was  known  as 
rapport.  Psychoanalysts  speak  of  it  as  transference  (of 
affection). 

In  the  growth  of  such  a  relationship  the  patient's  feeling 
toward  the  physician  may  become  one  of  sexual  love.  Under 
such  circumstances  the  physician  "  must  neither  drive  away 
the  transference  nor  must  he  return  it.  He  must  firmly 
grasp  the  phenomenon  as  a  temporary  manifestation  belong- 
ing only  to  the  period  of  treatment,  which  must  be  led  back 
to  its  unconscious  sources,  an  instrument  which  will  thus 
serve  to  bring  into  consciousness  the  most  hidden  part  of  the 
patient's  love  life  in  order  to  obtain  mastery  over  it.  There 
must  be  enough  permission  granted  to  the  love  to  allow  the 
patient  to  feel  herself  sufficiently  secure  to  produce  all  the 
stipulations,  phantasies  and  characteristics  of  her  erotic 
desires,  which  lead  the  way  into  their  infantile  sources." 
"  The  situation  as  far  as  the  physician  is  concerned  is  simply 
an  inevitable  part  of  the  treatment  for  which  he  must  assume 
the  responsibility  as  for  any  other  professional  confidence 
and  trust,  a  responsibility  that  is  only  increased  by  the 
ready   willingness   of   the   patient.     Technical   as   well   as 


PSYCHOANALYSIS  141 

ethical  motivos  determine  his  responsibihty  and  strengthen 
his  appreciation  of  the  therapeutic  value  of  this  situation. 
The  love  is  to  be  free^l  from  its  infantile  fixations,  not  in  order 
to  be  expended  in  the  course  of  the  treatment  but  to  be 
preserved  for  the  demands  of  real  life  for  which  the  treatment 
is  preparing  the  patient."  ^ 

In  psychoanalytic  work  considerable  use  has  been  made  of 
word-association  tests.^  The  technique  of  such  a  test  is 
described  in  Appendix  VI,  of  this  Manual.  In  the  main, 
however,  the  work  of  psychoanalysis — whether  in  the  study 
of  psychoneurotic  symptoms  or  of  dreams — consists  in  a 
procedure  described  by  Freud  as  follows: 

"  A  certain  psychic  preparation  of  the  patient  is  neces- 
sary. The  double  effort  is  made  with  him,  to  stimulate  his 
attention  for  his  psychic  perceptions  and  to  eliminate  the 
critique  with  which  he  is  ordinarily  in  the  habit  of  viewing 
the  thoughts  which  come  to  the  surface  in  him.  For  the 
purpose  of  self-observation  with  concentrated  attention,  it 
is  advantageous  that  the  patient  occupy  a  restful  position 
and  close  his  eyes;  he  must  be  explicitly  commanded  to  resign 
the  critique  of  the  thought  formations  which  he  perceives. 
He  must  be  told  further  that  the  success  of  the  psychoanalysis 
depends  upon  his  noticing  and  telling  everything  that  passes 
through  his  mind,  and  that  he  must  not  allow  himself  to  sup- 
press one  idea  because  it  seems  to  him  unimportant  or 
irrelevant  to  the  subject,  or  another  because  it  seems  non- 
sensical. He  must  maintain  impartiality  towards  his  ideas; 
for  it  would  be  owing  to  just  this  critique  if  he  were  unsuc- 
cessful in  finding  the  desired  solution  of  the  dream,  the  obses- 
sion, or  the  like." 

"  I  have  noticed  in  the  course  of  my  psychoanalytic  work 

^  S.  Freud.  Bemerkungen  u.  d.  Uebertragungsliebe.  Int.  Zeit.  f. 
Aerzt.  Psa.,  Vol.  Ill,  No.  1,  1915.  Quoted  by  S.  E.  Jelliffe.  The  Tech- 
nique of  Psychoanalysis.     New  York,  1918. 

^  C.  G.  Jung.  Diagnostische  Assoziationsstudien.  Vol.  I,  1906, 
Vol.  II,  1910. — E.  Jones.  The  Practical  Value  of  the  Word-Association 
Method  in  the  Treatment  of  Psychoneuroses.  Rev.  of  Neurol,  and  Psy- 
chiatry, Nov.,  1910. 


142  THE  PRACTICE  OF  PSYCHIATRY 

that  the  state  of  mind  of  a  man  in  contemplation  is  entirely 
different  from  that  of  a  man  who  is  observing  his  psychic 
processes.  In  contemplation  there  is  a  greater  play  of 
psychic  action  than  in  the  most  attentive  self-observation; 
this  is  also  shown  by  the  tense  attitude  and  wrinkled  brow 
of  contemplation,  in  contrast  with  the  restful  features  of 
self-observation.  In  both  cases,  there  must  be  concentration 
of  attention,  but,  besides  this,  in  contemplation  one  exercises 
a  critique,  in  consequence  of  which  he  rejects  some  of  the  ideas 
which  he  has  perceived,  and  cuts  short  others,  so  that  he 
does  not  follow  the  trains  of  thought  which  they  would  open ; 
toward  still  other  thoughts  he  may  act  in  such  a  manner 
that  they  do  not  become  conscious  at  all — that  is  to  say,  they 
are  suppressed  before  they  are  perceived.  In  self -observa- 
tion, on  the  other  hand,  one  has  only  the  task  of  suppressing 
the  critique;  if  he  succeeds  in  this,  an  unlimited  number  of 
ideas,  which  otherwise  would  have  been  impossible  for  him 
to  grasp,  come  to  his  consciousness.  With  the  aid  of  this 
material,  newly  secured  for  the  purpose  of  self -observation, 
the  interpretation  of  pathological  ideas,  as  well  as  of  dream 
images,  can  be  accomplished." 

"  The  suspension  thus  required  of  the  critique  for  these 
apparently  '  freely  rising  '  ideas,  which  is  here  demanded  and 
which  is  usually  exercised  on  them,  is  not  easy  for  some  per- 
sons. The  '  undesired  ideas '  are  in  the  habit  of  starting 
the  most  violent  resistance,  which  seeks  to  prevent  them 
from  coming  to  the  surface." 

"  Most  of  my  patients  accomplish  it  after  the  first  in- 
structions; I  myself  can  do  it  very  perfectly,  if  I  assist  the 
operation  by  writing  down  my  notions.  The  amount,  in 
terms  of  psychic  energy,  by  which  the  critical  activity  is 
in  this  manner  reduced,  and  by  which  the  intensity  of  the 
self-observ^ation  may  be  increased,  varies  widely  according 
to  the  subject  matter  upon  which  the  attention  is  to  be 
fixed." 

"  The  first  step  in  the  application  of  this  procedure  now 
teaches  us  that  not  the  dream  as  a  whole,  but  only  the  parts 


PSYCHOANALYSIS  143 

of  its  contents  separately,  may  be  made  the  object  of  our 
attention.  If  I  ask  a  patient  who  is  as  yet  mipracticed: 
'  What  occurs  to  you  in  connection  with  this  dream?  '  as 
a  rule  he  is  unable  to  fix  upon  anything  in  his  psychic  field  of 
vision.  I  must  present  the  dream  to  him  piece  by  piece, 
then  for  every  fragment  he  gives  me  a  series  of  notions,  which 
may  be  designated  as  the  '  background  thoughts  '  of  this  part 
of  the  dream." 

"  Comments  on  the  dream  and  seemingly  harmless  ob- 
servations about  it  often  serve  in  the  most  subtle  manner  to 
conceal — although  they  usually  betray — a  part  of  what  is 
dreamed.  Thus,  for  example,  when  the  dreamer  says:  Here 
the  dream  is  vague,  and  the  analysis  gives  an  infantile 
reminiscence  of  listening  to  a  person  cleaning  himself  after 
defecation.  Another  example  deserves  to  be  recorded  in 
detail.  A  young  man  has  a  veiy  distinct  dream  which  recalls 
to  him  phantasies  from  his  infancy  which  have  remained 
conscious  to  him:  he  was  in  a  summer  hotel  one  evening, 
he  mistook  the  number  of  his  room,  and  entered  a  room  in 
which  an  elderly  lady  and  her  two  daughters  were  undress- 
ing to  go  to  bed.  He  continues:  '  Then  there  are  some  gaps 
in  the  dream;  then  something  is  missing;  and  at  the  end 
there  was  a  man  in  the  room  who  wished  to  throw  me  out  with 
whom  I  had  to  wrestle.'  He  endeavored  in  vain  to  recall 
the  content  and  purpose  of  the  boyish  fancy  to  which  the 
dream  apparently  alludes.  But  we  finally  become  aware 
that  the  required  content  had  already  been  given  in  his 
utterances  concerning  the  indistinct  part  of  the  dream. 
The  '  gaps  '  were  the  openings  in  the  genitals  of  the  women 
who  were  retiring:  '  Here  something  is  missing  '  describes 
the  chief  character  of  the  female  genitals.  In  those  early 
years  he  burned  with  cmiosity  to  see  a  female  genital, 
and  was  still  inclined  to  adhere  to  the  infantile  sexual  theory 
which  attributes  a  male  genital  to  a  woman.' 

"  If  the  report  of  a  dream  appears  to  me  at  first  difficult 
to  unaerstand,  I  request  the  dreamer  to  repeat  it.  This  he 
rarely  does  in  the  same  words.     The  passages  wherein  the 


144  THE  PRACTICE  OF  PSYCHIATRY 

expression  is  changed  have  become  known  to  me  as  the  weak 
points  of  the  dream's  disguise."  "  The  analysis  may  start 
from  these  points." 

"  It  often  happens  that  in  the  midst  of  interpretation 
work  an  omitted  fragment  of  the  dream  suddenly  comes  to  the 
surface.  This  part  of  the  dream  snatched  from  forgetfulness 
is  always  the  most  important  part.  It  lies  on  the 
shortest  road  toward  the  solution  of  the  dream,  and 
for  that  very  reason  it  was  most  objectionable  to  the 
resistance." 

"  In  general  it  is  doubtful  in  the  interpretation  of  every 
element  of  the  dream  whether  it — (a)  is  to  be  regarded  as 
having  a  negative  or  a  positive  sense  (relation  of  opposi- 
tion); (6)  is  to  be  interpreted  historically  (as  a  reminis- 
cence) ;  (c)  is  symbolic ;  or  whether  (d)  its  valuation  is  to  be 
based  upon  the  sound  of  its  verbal  expression.  In  spite  of 
this  manifold  signification,  it  may  be  said  that  the  representa- 
tion of  the  dream  activity  does  not  impose  upon  the  trans- 
lator any  greater  difficulties  than  the  ancient  writers  of 
hieroglyphics  imposed  upon  their  readers." 

"  The  interpretation  of  a  dream  cannot  always  be  accom- 
plished in  one  session;  you  often  feel  after  following  up  a 
concatenation  of  thoughts,  that  your  working  capacity  is 
exhausted;  the  dream  will  not  tell  you  anything  more  on 
that  day;  it  is  then  best  to  break  off,  and  return  to  the 
work  the  following  day.  Another  portion  of  the  dream  con- 
tent then  solicits  your  attention,  and  you  thus  find  an 
opening  to  a  new  stratum  of  the  dream  thoughts.  We  may 
call  this  the  '  fractionary  '  interpretation  of  dreams." 

"  The  question  whether  every  dream  can  be  interpreted 
may  be  answered  in  the  negative.  One  must  not  forget 
that  in  the  work  of  interpretation  one  must  cope  with  the 
psychic  forces  which  are  responsible  for  the  distortion  of  the 
dream.  Whether  one  can  become  master  of  the  inner 
resistances  through  his  intellectual  interest,  his  capacity  for 
self-control,  his  psychological  knowledge,  and  his  practice 
in  dream  interpretation  becomes  a  question  of  the  prepon- 


PSYCHOANALYSIS  145 

derance  of  forces.  It  is  always  possible  to  make  some  prog- 
ress." ^ 

Cures  through  psychoanalysis  are  effected  by  bring- 
ing to  light  unconscious  complexes  underlying  psychoneurotic 
symptoms  and  thus  achieving  psychic  "  catharsis."  The 
patient  is,  of  course,  not  relieved  of  the  external  situation 
which  had  provoked  his  symptoms  as  a  diseased  form  of 
adjustment,  but  is  helped  to  a  normal,  i.e.,  a  more  purpose- 
ful and  more  social  form  of  adjustment. 

"  When  I  promised  my  patients  help  and  relief  through 
the  cathartic  method,  I  was  often  obliged  to  hear  the  fol- 
lowing objections:  '  You  say,  yourself,  that  my  suffering 
has  probably  to  do  with  my  own  relation  and  destinies. 
You  cannot  change  any  of  that.  In  what  manner,  then, 
can  you  help  me?  '  To  this  I  could  always  answer:  '  I 
do  not  doubt  at  all  that  it  would  be  easier  for  destiny  than 
for  me  to  remove  your  sufferings,  but  you  will  be  convinced 
that  much  will  be  gained  if  we  succeed  in  transforming 
your  hysterical  misery  into  everyday  unhappiness,  against 
which  you  will  be  better  able  to  defend  yourself  with  a 
restored  nervous  system.'  "  ^ 

Psychoanalysis  in  relation  to  psychoneuroses  and  psy- 
choses cannot  be  fully  treated  in  the  limited  space  that  is 
available  for  it  in  this  Manual.  For  further  study,  there- 
fore, the  student  must  be  referred  to  special  works.^ 

^  S.  Freud.  The  Interpretation  of  Dreams.  English  translation  by 
A.  A.  Brill.     New  York,  1916. 

2  S.  Freud.  Selected  Papers  on  Hysteria.  English  translation  by 
A.  A.  Brill.     New  York,  1909. 

^  S.  Freud.  Delusion  and  Dream. — E.  Hitschmann.  Freud's 
Theories  of  the  Neuroses.  English  translation  by  C.  R.  Payne. — 
H.  W.  Fritik.  Neurotic  Fears  and  Obsessions. — C.  G.  Jung.  The  Psy- 
chology of  Dementia  Prcecox.  English  translation  by  F.  Peterson  and 
A.  A.  Brill,  New  York,  1909. — A.  A.  Brill.  A  Case  of  Schizophrenia. 
Amer.  Jom^n.  of  Insanity,  July,  1909. — E.  Jones.  Psycho- Analytic 
Notes  on  a  Case  of  Hypomania.     Amer.  Journ.  of  Insanity,  Oct.,  1909. 


CHAPTER  X 
THE  PRACTICE  OF  PSYCHIATRY  {Continued) 

APPLICATIONS  OF  SOCIOLOGY  IN  PSYCHIATRY 

The  origin  of  social  work  is  found,  not  in  the  science  of 
sociology,  but  in  the  primitive  impulse  to  relieve  distress, 
which,  gradually  growing  into  organized  form  under  the 
auspices  of  the  church,  was  systematized  by  the  State,  and 
later  by  voluntary  associations.  At  the  present  time  we 
have  an  enormous  net-work  of  agencies,  religious,  govern- 
mental, and  private,  existing  for  the  prevention  and  relief 
of  social  disorder.  By  degrees  social  work  has  been  growing 
toward  a  realization  of  the  importance  of  seeking  out  funda- 
mental causes  of  distress  and  of  applying  the  principles  of 
sociology  to  social  problems.  While  the  sociologist  has 
been  becoming  more  concrete,  the  social  worker  has  been 
showing  more  scientific  potentiality.  Now  we  have  sociology 
and  social  work,  independent  in  their  origin,  coming  into 
closer  and  closer  association  leading  to  a  fusion  in  which 
social  work  appears  as  applied  sociology. 

At  the  same  time  that  social  work  has  been  approaching 
in  its  concepts  the  science  of  sociology,  it  has  been  coming  in 
practice  into  closer  relation  to  psychiatry.  In  the  begin- 
ning, the  concern  of  social  work  was  chiefly  economic  relief, 
but  eventually  it  came  to  be  also  physical  health.  Sickness 
was  found  to  accompany  poverty  in  75%  of  needy  cases. 
Within  a  few  years,  the  mental  factors  of  social  maladjust- 
ment have  been  coming  to  the  front  as  one  of  the  main 
interests  in  social  work. 

146 


APPLICATIONS  OF  SOCIOLOGY  147 

In  a  text-book  on  mental  disease/  written  by  a  state 
hospital  superintendent  over  twenty  years  ago,  we  find  a 
discussion  of  social  readjustment  as  an  important  part  of 
treatment.  Quoting  from  this  treatise,  "  Insanity,  practi- 
cally, is  loss  of  the  power  of  conformity  to  the  social  medium 
in  which  the  patient  lives.  This  power  is  regained  in  con- 
valescence gradually,  and  it  is  a  part  of  psychotherapy  to 
furnish  a  normal  personal  environment  to  which  the  patient 
is  to  practice  adjustment."  And  again,  "  The  physician 
who  has  conducted  a  case  of  mental  disorder  through  all  the 
vicissitudes  of  an  acute  attack  to  perfect  recovery  has  a 
final  duty  to  perform.  There  are  to  be  laid  down  definite 
rules  of  life,  points  in  physical  and  mental  hygiene,  sug- 
gestions of  the  best  way  to  meet  social  and  business  dif- 
ficulties, and  advice  as  to  domestic  relations."  It  was  some 
fifteen  years  later  that  systematic  provision  began  to  be  made 
for  seeing  that  these  "  rules  of  life  "  laid  down  by  the  physi- 
cian were  actually  followed  by  the  patient. 

The  first  attempt  in  this  country  to  employ  social  work  in 
the  care  of  patients  with  nervous  and  mental  disorders  seems 
to  have  been  in  the  Neurological  Clinic  of  the  Massachusetts 
General  Hospital  in  Boston  in  1905,  at  which  time  Dr.  James 
J.  Putnam,  who  was  in  charge  of  the  clinic,  engaged  a  social 
worker  and  trained  her  for  this  work.  Since  then  the  move- 
ment has  grown  rapidly.  Social  service  departments  have 
been  organized  in  psychiatric  clinics  and  hospitals  in  New 
York,  Massachusetts,  Illinois,  Michigan  and  elsewhere. 
In  the  World  War  the  American  army  established  well- 
organized  psychiatric  social  service  departments  in  mili- 
tary hospitals. 

Interrelation  of  Social  and  Mental  Disorders. — The  neces- 
sity for  close  cooperation  between  psychiatrist  and  sociolo- 
gist is  evident  when  it  is  considered  that  mental  disorder 
and  social  disorder  are  but  two  aspects  of  the  same  condition. 


^  Kellogg,  Theodore  H.,  M.D.     A  Text-Book  of  Mental  Diseases. 
New  York,  1897,  pp.  501  and  515. 


148  THE  PRACTICE  OF  PSYCHIATRY 

The  interrelation  of  mental  and  social  conditions  appears 
with  particular  distinctness  in  two  recently  conducted  county- 
surveys  of  mental  disorders.^  The  object  of  the  Survey 
in  Nassau  County,  New  York,  is  stated  as  follows: 

"  The  principal  question  raised  is  not.  What  is  the  per- 
centage of  '  insane  '  or  '  feeble-minded  '  or  '  mentally  defec- 
tive '  persons  in  the  population?  But  rather,  What  instances 
of  social  maladjustment  sufficiently  marked  to  have  become 
the  concern  of  public  authorities,  are,  upon  investigation,  to 
be  attributed  mainly  or  in  large  measure  to  mental  disorders? 
Thus  the  main  object  of  the  Survey  was  to  study  the  nature 
of  the  relationship  between  social  maladjustments  and 
mental  disorders." 

Out  of  1592  abnormal  cases  found  in  the  county,  only  163 
or  10.2%  showed  no  social  maladjustment,  all  the  others 
havjng  shown  social  maladjustment  of  one  or  more  of  the 
following  specified  types:  (a)  Retardation  in  school,  (6) 
Truancy,  unruHness,  (c)  Sex  immorality,  {d)  Criminal  tend- 
ency, (e)  Vagrancy,  (/)  Dependency,  {g)  Inebriety,  Qi)  Drug 
habits,  {%)  Domestic  maladjustment,  (j)  Medical  cases. 

In  this  connection,  the  position  taken  by  the  President 
of  The  National  Committee  for  Mental  Hygiene,^  may 
be  quoted  as  a  criterion:  "  If  sociology  is  the  science  that 
deals  with  social  forces,  social  structures  and  institutions, 
social  functions,  and  social  progress  (genetic  and  telic), 
the  mere  statement  of  the  fact  is  surely  sufficient  evidence 
of  the  importance  of  this  science  to  the  student  and  practi- 
tioner of  mental  hygiene." 


^  Aaron  J.  Rosanoff,  M.D.  Report  of  a  Survey  of  Mental  Disorders 
in  Nassau  County,  New  York.  National  Committee  for  Mental  Hygiene, 
1916. — Herman  M.  Adler,  M.D.  Cook  County  and  the  Mentally  Handi- 
capped: A  Study  of  the  Provisions  for  Dealing  with  Mental  Problems  in 
Cook  County,  Illinois.  Report  of  Survey,  1916-1917.  National  Com- 
mittee for  Mental  Hygiene,  1918. 

2  Lewellys  F.  Barker.  The  First  Ten  Years  of  the  National  Commit- 
tee for  Mental  Hygiene,  with  Some  Comments  on  its  Future.  Mental 
Hygiene.     Oct.,  1918. 


APPLICATIONS  OF  SOCIOLOGY  149 

The  Psychiatric  Social  Worker. — By  reason  of  general 
recognition  of  the  above  a  demand  has  arisen  for  psychiatric 
social  work  and  special  training  is  being  provided.^ 

Not  everybody  is  equipped  for  psychiatric  social  work. 
The  psychiatric  social  worker  must  be  a  person  with  certain 
natural  qualifications.  She  must,  of  course,  be  inteihgent, 
well-balanced,  sjTnpathetic,  and  adaptable,  with  the.abihty 
to  meet  all  sorts  of  persons  and  a  manner  that  wins  confi- 
dence. She  must  have  a  strong  interest  in  individuals  and 
a  liking  to  follow  them  into  the  scenes  of  their  daily  fives. 
She  needs  considerable  patience.  Ability  to  think  clearly 
and  to  make  close  observations  is  indispensable.  A  high 
degree  of  disinterestedness  is  essential;  for  the  social  worker 
must  be  ready  at  all  times  to  give  service  to  the  patients  with- 
out discrimination. 

Training  for  psychiatric  social  work  assumes  a  preliminary 
foundation  in  biology,  psychology,  sociology,  economics, 
and  political  science.  In  addition  to  these  fundamental 
branches,  there  should  be  courses  in  social  legislation,  social 
statistics,  labor  problems,  organization  of  social  work, 
and  training,  with  practice  work  in  the  technique  of  social 
case  work.  There  should  also  be  elementary  instruction 
in  the  essentials  of  medicine.  Finally,  there  should  be  a 
course  in  social  psychiatry,  which  would  include  the  prin- 
ciples of  mental  hygiene,  the  main  groups  and  simpler 
indicators  of  mental  disorders  with  a  general  view  of  their 
governmental,  social,  family,  and  personal  significances. 

Opportunities  for  practice  work  have  been  afforded  to 
students  in  various  mental  clinics  and  through  interne- 
ships  and  externeships  in  certain  hospitals  for  mental 
disease,  including  Manhattan  and  Brooklyn  State  Hospitals, 

^  George  M.  IvLLne.  Social  Service  in  the  State  Hospital.  Proceed- 
ings, American  Medico-Psychological  Association,  1916. — C.  Macfie 
Campbell,  M.D.  The  Mental  Health  of  the  Community  and  the  Work 
of  the  Psychiatric  Dispensary.  Mental  Hygiene,  Oct.,  1917. — E.  E. 
Southard.  Mental  Hygiene  and  Social  Work:  Notes  on  a  Course  in 
Social  Psychiatry  for  Social  Workers.     Mental  Hygiene,  July,  1918. 


150  HF  PRACTICE  OF  PSYCHIATRY 

in  New  York,  and  Boston  State  and  Psychopathic  Hospi- 
tals, in  Massachusetts. 

The  first  systematic  course  of  this  kind  to  be  given  was 
the  war  emergency  course  conducted  by  Smith  College 
and  the  Boston  Psychopathic  Hospital  (1918-1919). ^  Out 
of  this  course  grew  the  Smith  College  Training  School  for 
Social  Work,  in  which  training  in  psychiatric  social  work  is 
offered.  Similar  courses  are  given  at  the  New  York  School 
of  Social  Work,  New  York,  and  the  Pennsylvania  School 
of  Social  Service,  Philadelphia. 

The  psychiatric  social  worker  is  to  be  found  not  only  in 
hospitals,  but  wherever  psychiatrists  are  engaged  in  the 
study  and  treatment  of  mental  disorders.  In  courts, 
reformatories,  schools,  social  agencies  the  social  worker 
with  special  knowledge  of  neuro-psychiatric  cases  is  needed. 
There  are  signs  that  it  may  not  be  long  before  large  indus- 
tries maintaining  a  medical  service  for  employees  shall 
have  psychiatrists  on  their  medical  staffs.  It  is  probable 
that  industrial  hygiene  will  soon  be  extended  to  include 
mental  hygiene.  In  that  case  a  new  demand  for  psychiatric 
social  workers  will  be  created. 

Functions  of  a  Sociological  Department. — The  sociologi- 
cal or  social  service  department  of  a  hospital  for  mental 
diseases  has  functions  related  to  (a)  diagnosis,  (6)  treatment, 
(c)  research,  and  (d)  education.  Every  patient  admitted 
requires  consideration  of  his  social  condition  as  well  as  of 
his  mental  condition.  In  many  cases  a  medical  diagnosis 
can  not  be  made  without  knowledge  of  the  patient's  social 
history.  In  some  cases  prolonged  observation  of  the  patient 
in  the  community  is  essential  to  a  diagnosis. 

1  The  Training  School  of  Psychiatric  Social  Work  at  Smith  College: 
I.  Educational  Significance  of  the  Course,  by  W.  A.  Neilson.  II.  A 
Lay  Reaction  to  Psychiatry,  by  E.  E.  Southard.  III.  The  Course  in 
Social  Psychiatry,  by  Edith  R.  Spaulding.  IV.  A  Scientific  Basis  for 
Training  Social  Workers,  by  F.  Stuart  Chapin.  V.  An  Emergency 
Course  in  a  New  Branch  of  Social  Work,  by  Mary  C.  Jarrett.  Mental 
Hygiene,  Oct.,  1918. 


APPLICATIONS  OF  SOCIOLOGY  151 

In  order  to  obtain. a  full  history  it  is  usually  necessary  to 
go  out  into  the  communitij  to  make  inquiries.  Medical  work 
is  facilitated,  and  complete  histories  are  insured,  when 
this  function  is  delegated  to  a  worker  trained  in  social 
investigation. 

The  history  secured  by  the  social  worker  from  informants 
in  the  community  to  aid  the  physician  in  his  diagnosis  will 
contain  essentially  the  same  information  that  he  might 
obtain  himseK  if  these  informants  should  come  to  the 
hospital.  The  discussion  of  history  taking  in  Chapter  V 
will  therefore  guide  the  social  worker  in  this  connection,     v 

In  addition  to  the  information  required  for  medical 
diagnosis,  certain  sociological  data  are  required  by  the  social 
worker  in  order  to  understand  the  patients'  social  condition 
and  to  provide  the  best  possible  social  care.  To  begin  with, 
names  and  addresses  of  relatives,  employers,  neighbors, 
teachers,  clerg;>anen,  friends  must  be  noted  exactly,  so  that 
these  persons  may  be  visited  as  sources  of  information. 
These  addresses  are  also  necessary  because  the  social  worker 
must  discover  what  beneficial  resources  exist  in  the  patient's 
environment  and  who  among  his  relatives  and  acquaint- 
ances would  be  helpful  in  supplying  the  assistance  that  he 
needs  for  social  adjustment.  The  character  of  his  home  and 
the  neighborhood  in  which  he  lives  must  be  gone  into  care- 
fully both  through  inquiry  and  direct  observation,  in  order 
to  effect  improvement  in  his  surroundings  if  unsuitable 
conditions  are  found.  It  is  important  to  have  fairly  com- 
plete knowledge  of  all  members  of  the  family  group  and 
other  relatives  who  may  be  closely  associated  with  the 
patient.  The  attitude  of  the  family  toward  the  patient 
is  a  matter  of  special  concern.  The  ratio  between  income  and 
expenditures  of  the  patient,  or  of  the  family  group  to  which 
he  belongs,  and  the  relation  between  income  and  standard 
of  living  are  matters  of  great  practical  importance  in  social 
care. 

History  from  the  patient  through  direct  examination  by 
the  social  worker  is  also  essential,  as  data  of  sociological 


152        THE  PRACTICE  OF  PSYCHIATRY 

significance  are  required,  which  the  phj^sician  either  does  not 
obtain  at  all  or  obtains  without  sufficient  detail  for  the 
purpose  of  social  work.  The  social  worker  will  of  course 
avoid  duplication  of  work  already  covered  by  the  medical 
examination.  Among  points  of  special  concern  to  the  social 
worker  are:  What  are  the  patient's  own  plans  for  his  future? 
Has  he  satisfactory  living  conditions  in  view?  Has  he  a 
prospect  of  suitable  employment?  What  financial  resource 
has  the  patient?  If  employed,  the  question  arises  whether 
he  is  receiving  suitable  wages  or  might  better  his  condition. 
The  matter  of  financial  assistance  from  the  proper  social 
agency  must  be  taken  up  in  needy  cases.  The  patient's 
attitude  toward  his  family  is  an  important  consideration  in 
social  treatment.  It  is  desirable  to  know  which  members 
of  his  family  have  most  influence  with  him.  The  character 
of  the  patient's  friends  and  companions  is  to  be  learned 
partly  from  hmi  and  partly  by  inquiry  from  other  sources. 
His  attitude  toward  them  and  the  extent  to  which  they 
influence  him  should  be  inquired  into.  The  tastes  and 
preferences  of  the  patient  in  regard  to  emploj^ment,  recrea- 
tion, and  occupation  in  leisure  time  must  be  learned  to  some 
extent  by  direct  examination.  Clues  for  further  inquiry  to 
secure  history  must  be  obtained  with  full  names  and  ad- 
dresses. The  general  social  and  educational  background  of 
informants  w^ho  are  to  be  seen  or  written  to  is  of  great  im- 
portance. An  mquiry  is  hkely  to  be  more  fruitful  if  the  in- 
vestigator knows  something  of  the  character  of  the  person 
approached.  This  is  particularly  true  where  the  inquiry 
must  be  made  by  letter,  and  is  of  even  more  importance 
perhaps  where  the  inquuy  is  made  over  the  telephone. 
Finally  in  talking  with  the  patient,  the  social  worker  es- 
tablishes an  intunacy  which  she  must  develop  if  she  is  to 
deal  successfully  with  the  intimate  problems  of  his  social 
life. 

Another  aid  to  diagnosis  in  connection  with  out-patient 
clinics  is  prolonged  observation  through  the  social  service  of 
doubtful  cases  in  the  community.     Reports  of  the  patient's 


APPLICATIONS  OF  SOCIOLOGY  153 

behavior  at  home  brought  in  by  the  social  worker  and  notes 
on  the  way  in  which  the  patient  responds  to  the  efforts  of 
the  social  worker  to  improve  his  social  condition  are  often 
the  means  of  reaching  a  correct  diagnosis  in  a  dubious  case. 

In  treatment,  the  work  of  the  social  service  is  almost 
entirely  with  out-patients  (both  those  who  have  been  in 
hospital  and  those  who  have  not),  although  some  assistance 
is  given  in  the  treatment  of  patients  in  the  hospital  in  such 
ways  as  setting  in  order  difficulties  at  home,  furnishing 
assurance  that  suitable  conditions  for  discharge  will  be 
ready,  and  relieving  the  patient  of  other  real  anxieties. 
The  responsibility  to  out-patients  is  two-fold:  to  secure 
to  the  patient  continued  medical  treatment  by  following 
him  up  if  he  fails  to  come  back  to  see  the  physicians  as 
directed;  and  to  see  that  he  is  socially  adjusted  in  respect 
to  home,  friends,  recreation,  employment. 

This  second  duty  is  the  special  function  of  social  case 
work — to  organize  all  factors  existing  within  the  individual 
and  his  environment  to  effect  the  best  possible  adaptation 
of  that  individual  to  society.  In  this  process  the  welfare 
of  ^he  family  group  must  also  receive  attention  since  it 
closely  affects  the  welfare  of  the  patient.  The  treatment 
of  some  patients,  as  Dr.  Adolf  Meyer  has  said,  is  treatment 
of  the  environment.  Not  infrequently  the  physician  finds 
the  difficulty  to  be  entirely  social  and  leaves  the  case  in  the 
hands  of  the  social  worker.  In  most  cases  medical  treat- 
ment needs  to  be  supplemented  and  reinforced  by  social 
care. 

The  recent  development  of  out-patient  clinics  connected 
with  state  hospitals  has  created  an  important  demand  for 
social  work.  In  several  states  each  state  hospital  now 
conducts  one  or  more  clinics  held  either  at  the  hospital  or  in 
a  neighboring  center  of  population.^  The  services  of 
social  workers  are  indispensable  in  these  clinics. 

An  important  service  of  the  social  worker  in  a  state  hos- 

^  New  York  State  Hospital  Commission.  Thirtieth  Annual  Report, 
1917-1918. 


154  THE  PRACTICE  OF  PSYCHIATRY 

pital  is  in  connection  with  the  after-care  of  paroled  patients. 
In  New  York  "  the  average  daily  number  of  patients  on 
parole  from  the  13  civil  state  hospitals  during  the  year 
(1917)  was  1504  compared  with  1346  in  1916,  1280  in  1915, 
1141  in  1914,  and  978  in  1913."  "  The  employment  of  field 
workers  by  the  state  hospitals  and  the  establishment  of 
additional  clinics  by  the  various  institutions  undoubtedly 
is  responsible  in  a  considerable  measure  for  the  increase  in 
the  number  of  patients  on  parole."  ^  The  reports  point  out 
the  financial  benefits  of  the  parole  system  in  saving  main- 
tenance and  making  room  for  new  patients,  thereby  pre- 
venting overcrowding,  as  well  as  the  more  important  advan- 
tage that  the  recovery  of  patients  is  often  hastened,  "  when 
they  can  return  to  their  own  homes  and  familiar  surroundings 
to  complete  the  period  of  convalescence  and  at  the  same  time 
continue  under  the  watchful  eye  of  the  hospital.  The 
hospital  keeps  in  touch  with  these  patients  through  its 
social  workers  who  visit  the  homes  before  patients  are 
paroled  and  who  make  periodical  visits  afterwards  to  see 
that  conditions  are  satisfactory  and  that  the  patient  is 
living  in  a  manner  calculated  to  prevent  a  recurrence  of  the 
disease,  or,  if  a  patient  is  not  recovering  satisfactorily,  to 
see  that  he  or  she  is  returned  to  the  hospital  for  proper 
treatment." 

In  research,  social  investigation  is  required  in  many 
studies  of  mental  disease  that  call  for  previous  history  and 
continued  observation  of  cases  in  the  community.  Experi- 
mental medical  work  in  neuro-syphilis  is  largely  dependent 
upon  social  assistance  in  keeping  patients  faithful  to  treat- 
ment and  in  inducing  other  members  of  the  family  to  be 
examined  and,  if  necessary,  treated.  Certain  psychiatric 
problems  can  not  be  studied  successfully  without  social 
work,  such  as  the  care  of  the  feeble-minded  at  home,  the 
training  of  delinquents,  the  adjustment  of  the  psychopathic 
employee.     In   studies  of  heredity,   social  investigation  is 

1  New  York  State  Hospital  Commission.  Twentij-ninth  Annual 
Report,  1916-1917. 


APPLICATIONS  OF  SOCIOLOGY  155 

essential.  At  the  Eugenics  Record  Office,  Cold  Spring 
Harbor  N.  Y.,  a  special  course  is  given  annually  to  train 
field  workers  for  this  purpose. 

In  public  educatioyi,  social  workers  have  an  unusual  oppor- 
tunity to  spread  the  facts  and  principles  of  mental  hygiene 
through  their  varied  and  numerous  contacts  in  the  com- 
munity. Interest  that  began  in  a  social  inquiry  about 
a  particular  case,  may  lead  a  teacher,  clergyman,  or  em- 
ployer to  better  knowledge  of  the  subject  of  mental  disease 
and  mental  hygiene.  The  training  of  students  in  psychiatric 
social  work  is  an  important  educational  responsibility. 

Organization  of  a  Sociological  Department. — The  organ- 
ization of  a  sociological  department  in  a  hospital  conducting 
an  out-patient  clinic  must  make  provision  primarily  for 
social  work  contributing  to  diagnosis  and  treatment.  The 
routine  duties  may  be  divided  into  (a)  securing  histories, 
(6)  follow-up  work,  (c)  social  case  work.  These  duties  may 
be  performed  by  different  workers  or  united  in  any  com- 
bination in  one  worker;  but  it  is  important  that  the  three 
forms  of  service  should  be  distinguished,  in  order  that  each 
receive  due  attention. 

A  social  worker  in  attendance  at  the  out-patient  clinic 
takes  a  history  from  the  patient  as  a  basis  for  the  medical 
examination,  and  at  the  same  time  inquires  into  his  social 
condition  to  discover  environmental  difficulties  calling  for 
social  treatment.  The  same  worker  will  see  that  patients 
and  friends  accompanying  them  understand  the  physician's 
directions  and  are  disposed  to  follow  them.  For  history 
taking  in  the  hospital,  a  special  worker,  who  by  practice 
becomes  expert,  is  of  great  assistance  to  the  medical 
staff. 

By  follow-up  work  is  meant  keeping  informed  by  a  card 
system  of  the  failure  of  patients  to  keep  their  appointments 
and  inducing  them,  by  letter,  telephone,  or  visit,  to  report. 
This  might  seem  to  be  merely  clerical  work,  but  it  will  be 
found  to  require  fine  judgment  and  the  interest  and  point 
of  view  of  the  social  worker,  the  results  obtained  being  in 


156  THE  PRACTICE  OF  PSYCHIATRY 

proportion  to  the  presence  of  these  factors.^  By  this 
service  also  a  patient  dismissed  by  the  physicians  for  six 
months  or  a  year  may  be  automatically  brought  back  at  the 
end  of  that  time  or  reported  upon  by  the  social  worker,  if 
unable  or  unwilling  to  make  a  visit.  The  follow-up  work 
for  syphilitic  patients  is  especially  important.  Another 
form  of  follow-up  work  is  a  routine  method  of  seeking  the 
relatives  of  all  patients  with  a  positive  Wassermann  reaction 
and  bringing  them  to  the  clinic  for  examination.^ 

As  nearly  every  case  of  mental  disorder  presents  some 
problem  of  social  maladjustment,  a  routine  social  examina- 
tion of  every  admission  should  be  made.  Where  the  social 
staff  is  insufficient,  which  is  almost  invariably  the  case,  the 
determination  of  the  need  of  social  care  is  necessarily  left 
to  the  physicians,  who  refer  cases  to  the  social  service. 
But  the  physician  is  not  accustomed  to  look  for  social 
disorder  nor  familiar  enough  with  social  practice  to  know 
the  possibilities  of  social  care;  so  that  he  is  likely  to  refer 
only  cases  of  social  disorder  that  are  conspicuously  acute 
or  urgent. 

The  amount  of  time  required  for  social  case  work  is  pro- 
portionately greater  than  the  time  required  by  medical  work, 
for  the  patients  under  social  care  are  widely  scattered  in  the 
community  and  may  need  more  or  less  close  attention  for 
months  or  years.  As  no  hospital  has  yet  a  staff  of  social 
workers  even  approximately  adequate  for  the  work,  there  is 
a  method  in  use  of  classifying  social  cases  as  either  "  inten- 
sive "  or  "  slight  service  "  cases  according  to  the  degree  of 
responsibility  assumed  by  the  social  service.  "  Slight  ser- 
vice "  cases  are  those  in  which  assistance  is  given  without 
inquiry  beyond  the  apparent  facts.  In  an  intensive  case  the 
social  service  attempts  to  assume  responsibility  for  making 
a  full  inquiry  into  the  social  condition  of  the  patient  and  his 

1  E.  E.  Southard.  Report  of  the  Director  of  the  Psychopathic  Depart- 
ment of  the  Boston  State  Hospital,  1917. 

2  E.  E.  Southard.  Report  of  the  Director  of  the  Psychopathic  Depart- 
ment of  the  Boston  State  Hospital,  1918. 


APPLICATIONS  OF  SOCIOLOGY  157 

family,  and  endeavors  to  secure  the  largest  measure  of  social 
well-being  possible  for  both  patient  and  family. 

It  has  been  estimated  that  75%  of  all  admissions  will 
call  for  some  form  of  social  attention,  which  25%  may 
receive  from  social  agencies  in  the  community,  so  that  50% 
should  receive  social  care  from  the  social  service  of  the  hos- 
pital. As  a  social  worker  can  not  care  for  more  than  100 
to  150  cases  a  year  adequately,  a  worker  is  needed  for  every 
200  to  300  admissions. 


CHAPTER  XI 

THE  PRACTICE  OF  PSYCHIATRY  (Continued) 

PROGNOSIS— PREVALENCE  OF  MENTAL  DISORDERS:   ARE 
THEY  ON  THE  INCREASE? 

Prognosis. — In  the  early  part  of  the  nineteenth  century, 
when  the  care  of  the  insane  had  passed  from  the  hands  of 
the  clergy,  penal  authorities,  and  poor-law  officials  to  those 
of  physicians,  the  hope  was  widely  entertained  that  the  medi- 
cal treatment  which  thus  became  available  for  the  insane 
would  result  in  high  percentages  of  cures.  Thus,  in  one 
of  the  most  important  documents  in  the  history  of  psychiatry 
in  this  country,  a  report  under  date  of  March  29,  1834,  made 
to  the  New  York  state  legislature  by  a  special  committee, 
we  read:  "It  is  now  satisfactorily  established  that  diseases 
of  the  mind  yield  even  more  readily  to  medical  treatment 
than  those  of  the  body,  and  that  in  at  least  nine-tenths  of 
the  cases  of  insanity  the  patient  may  be  restored  to  the 
full  enjoyment  of  his  mental  faculties  by  the  early  applica- 
tion of  judicious  medical  treatment."  To-day  not  the  most 
sanguine  in  the  psychiatric  branch  of  the  medical  profes- 
sion would  make  such  an  assertion.  The  prognosis  of 
psychotic  disease  is  more  correctly  indicated  by  the  follow- 
ing analysis  of  the  recovery  statistics  of  the  Kings  Park 
State  Hospital,  at  Kings  Park,  New  York,  for  the  year  end- 
ing September  30,  1915. 

Two  hundred  and  fourteen  cases  were  discharged  during 
the  year  as  "  recovered,"  making  the  recovery  rate,  based 
on  direct  admissions,  20.78%.  Many  of  these  reported  recov- 
eries, however,  can  be  regarded  as  such  only  from  a  non- 
158 


PROGNOSIS  159 

medical  point  of  view;  for  of  these  cases  31  were  suffering 
at  the  time  of  their  discharge  from  epilepsy,  imbecility, 
constitutional  inferiority,  or  paralysis  agitans,  having  re- 
covered merely  from  their  "  insanity,"  i.e.,  from  acute 
psychotic  manifestations  which  had  led  to  their  commitment; 
49  had  had  one  or  more  previous  admissions  to  institutions 
and  were  evidently  recurrent  cases  without  likelihood  of 
continued  mental  health  in  the  future;  13  had  recovered  from 
alcohoHc  psychoses  but  probably  not  from  the  habit  of  in- 
temperance; and  24  had  been  classed  as  constitutionally 
of  inferior  or  defective  make-up  and  had  recovered  not, 
of  course,  from  their  inferiority  or  defectiveness  but,  like 
the  first  mentioned  group,  merely  from  acute  psychotic 
manifestations  which  had  led  to  their  commitment. 

This  leaves  but  97  cases  which  can  be  said  to  have 
recovered  in  the  sense  of  having  shown  at  the  time  of  their 
discharge  a  real  freedom  from  demonstrated  psychic 
abnormality.  But  if  the  universal  past  experience  is  a  trust- 
worthy guide,  then  it  is  unfortunately  but  too  sure  that  a 
certain  proportion  even  of  this  remnant  will  prove  sooner  or 
later  to  be  of  a  recurrent  nature;  so  that  it  is  extremely 
doubtful  if  complete  and  permanent  recoveries  have  occurred 
in  more  than  5%  of  all  cases  admitted. 

It  should  be  added  here  that  the  experience  of  the  Kings 
Park  State  Hospital  is,  in  this  respect,  by  no  means  unique; 
on  the  contrary,  it  is  but  the  general  experience  of  psychia- 
tric practice  all  over  the  world,  as  may  be  judged  from  the 
following  passage  quoted  from  Kraepelin:  ^  "  Only  a  com- 
paratively small  percentage  of  cases  are  permanently  and 
completely  cured  in  the  strictest  sense  of  the  word."  This 
statement,  we  believe,  voices  the  concensus  of  competent 
psychiatric  opinion. 

It  would  seem  from  this  that  radical  dealing  with  the 
problems  of  mental  disease  must  be  by  way  of  prevention 
and  not  treatment. 

^  Kraepelin.  Lectures  on  Clinical  Psychiatry.  Second  edition  in 
English,  New  York,  1906.     P.  2. 


160  THE  PRACTICE  OF  PSYCHIATRY 

Prevalence  of  Mental  Disorders:  Are  They  on  the 
Increase?! — During  the  past  several  decades  the  number  of 
insane  in  institutions  has  been  increasing  at  a  faster  rate 
than  the  general  population.  Thus,  according  to  the 
United  States  census  statistics  there  were,  in  1880,  81.6 
patients  in  institutions  for  the  insane  per  hundred  thousand 
of  the  general  population;  in  1910  the  number  had  risen 
to  204.2.  To  what  extent,  if  any,  does  this  fact  indicate 
an  actual  increase  in  the  prevalence  of  mental  disorders 
in  the  American  population? 

There  can  be  no  doubt  that,  at  least  to  some  extent, 
the  increase  of  patients  in  institutions  is  due  merely  to  the 
general  improvement  in  the  kind  and  adequacy  of  facilities 
for  their  care;  and  if  the  statistics  of  various  states  for  any 
one  year  are  compared  with  one  another,  marked  differences 
are  found,  corresponding  to  stages  of  progress  in  social  organi- 
zation, and  altogether  analogous  to  those  shown  by  the 
entire  country  in  years  separated  by  decades. 

Thus,  for  instance,  in  1910  there  were  in  the  state  of 
Oklahoma  67  patients  in  institutions  per  hundred  thousand 
of  the  general  population,  whUe  in  the  state  of  Massachusetts 
there  were  344.6;  and  between  these  extremes  all  degrees 
of  transition  were  presented  by  the  statistics  of  other  states. 

It  is  obvious,  therefore,  that  the  number  of  patients 
in  institutions,  either  in  the  entire  country  at  different 
times  or  in  different  parts  of  it  at  any  one  time,  cannot  be 
taken  as  a  correct  measure  of  the  prevalence  of  mental 
disorders  among  the  people. 

For  this  reason,  attempts  have  been  repeatedly  made  to 
enumerate  the  total  number  of  insane  persons  both  in  and 
out  of  institutions  in  the  various  states.^  The  resulting 
data  were,  however,  so  manifestly  untrustworthy  that  event- 
ually it  became  apparent  that  the  difficulties  inherent  in  such 
an  undertaking  were  greater  than,  for  the  present,  we  can 

1  A.  J.  Rosanoff.  7s  Insanity  on  the  Increase?  Journ.  Amer.  Med. 
Ass'n,  July  24,  1915. 

2  U.  S.  Census  from  1850  to  1890. 


PREVALENCE  OF  MENTAL  DLSORDERS         161 

cope  with  successfully,  and  such  attempts  have,  accordingly, 
been  given  up. 

Of  these  difficulties  the  greatest  and,  perhaps,  the  sole 
insurmountable  one  is  that  of  formulating  such  a  definition 
of  insanity  as  to  enable  enumerators  readily  and  uniformly 
to  distinguish  between  sane  and  insane  persons,  under  all 
conditions. 

Furthermore,  whoever  is  familiar  with  psychiatric 
clinical  material  knows  that,  owing  to  the  nature  of  things, 
even  if  it  were  possible  to  formulate  a  definition  and  thereby 
draw  a  line  sharply  distinguishing,  for  practical  purposes, 
sanity  from  insanity,  the  line  could  be  thus  drawn  only  in 
relation  to  some  more  or  less  arbitrary  standard  of  normality. 

The  need  of  standards  of  normality  is  felt  not  only  in 
connection  with  attempts  of  enumeration  of  the  insane  in 
communities,  but  also  in  daily  practice  in  connection  with 
every  case  of  alleged  insanity  in  which  commitment  to  an 
institution  is  sought;  and  in  this  respect  the  practice  of  the 
various  states,  vaiying  as  it  does  within  wide  limits,  indicates 
the  apphcation  of  a  whole  series  of  fairly  distinct,  though 
not  readily  definable,  standards. 

Thus,  referring  again  to  the  instances  presented  by 
Oklahoma  and  Massachusetts,  significance  attaches  mainly 
to  the  consideration  that  there  are  undoubtedly  many  per- 
sons residing  in  the  former  state  who  are  at  large  and  whom, 
moreover,  their  fellow  citizens  do  not  consider  proper  sub- 
jects for  an  insane  hospital,  but  who  would  be  promptly 
committed  if  they  took  ,up  their  residence  in  the  latter  state. 
In  the  last  analysis,  it  is  a  difference  in  tacitly  accepted 
standards  of  normality  that  accounts  largely  for  the  fact 
that  in  Oklahoma,  as  already  stated,  there  were  but  67 
patients  in  institutions  per  hundred  thousand  of  the  general 
population,  while  in  Massachusetts  there  v/ere  no  less  than 
344.6;  and  similar  differences  in  standards  no  doubt  account 
for  the  analogous  contrasts  presented  by  statistics  of  the 
insane  in  institutions  in  the  entire  country  at  different 
times. 


162  THE  PRACTICE  OF  PSYCHIATRY 

Persons  are  placed  in  institutions  when,  by  reason  of 
some  mental  defect  or  disturbance,  their  adaptation  to  their 
environment  fails.  The  environment  of  a  highly  organized 
community  with  high  standards  of  living  is,  of  course,  more 
exacting  than  that  of  a  community  characterized  by  a  more 
primitive  organization  and  lower  standards. 

Whatever  may  be  one's  theoretical  conception  of  insan- 
ity, the  line  of  division  between  it  and  the  normal  condition, 
as  it  is  indicated  by  the  practice  of  communities,  is  a  shift- 
ing one,  moving  from  the  abnormal  toward  the  normal  ex- 
treme with  the  progress  of  civilization  and  the  concomitant 
elevation  of  social  standards. 

These  considerations  are  of  importance,  as  they  point 
a  way  to  an  indirect  method  of  investigating  the  question 
which  is  before  us.  Are  mental  disorders  on  the  increase? 
For,  although  it  would  be,  of  course,  impossible  to  apply 
a  newly  selected  standard  to  conditions  in  the  remote  past 
concerning  which  we  have  no  information  other  than  that 
recorded  by  contemporary  observers,  it  is  at  least  within 
the  bounds  of  possibility  to  apply  such  a  standard  in  studying 
I  conditions  in  various  parts  of  the  country  as  they  exist  in 
our  own  time. 

The  states  east  of  the  Mississippi  River  may  be  divided 
into  a  Northern  group,  comprising  Connecticut,  Illinois, 
Indiana,  Maine,  Massachusetts,  Michigan,  New  Hampshire, 
New  Jersey,  New  York,  Ohio,  Pennsylvania,  Rhode  Island, 
Vermont,  and  Wisconsin;  and  a  Southern  group,  com- 
prising Alabama,  Delaware,  Florida,  Georgia,  Kentucky, 
Maryland,  Mississippi,  North  Carolina,  South  Carolina, 
Tennessee,  Virginia,  and  West  Virginia. 

Facilities  for  the  care  of  the  insane  have  at  all  times 
been  relatively  more  ample  in  the  Northern  group  of  states, 
and,  accordingly,  the  number  of  patients  in  institutions  in 
relation  to  the  general  population  has  always  been  greater, 
as  shown  in  the  accompanying  table. 

The  difference  between  these  two  groups  of  states  is 
certainly  very  striking.     From  what  has  been  said  it  would 


PREVALANCE  OF  MENTAL  DISORDERS  163 

follow  that  the  question,  To  what  extent  does  this  differ- 
ence correspond  with  a  real  difference  in  incidence  of  insan- 
ity? is  lacking  in  definiteness.  It  may  be  better  expressed 
as  follows:  If  the  populations  of  the  two  groups  of  states, 
or  representative  portions  of  them,  were  exposed  to  the 
same  environmental  conditions,  would  there  still  be  a  differ- 
ence between  them  as  to  the  proportion  of  patients  con- 
tributed to  insane  hospitals;  and,  if  so,  which  group  would 
contribute  the  higher  proportion  and  how  great  would  be 
the  difference? 

TABLE  6. 

Number  of  Insane  in  Institutions  per  Hundred  Thousand  op 
THE  General  Population  in  Certain  Years  in  Two  Groups 
OF  States  East  of  the  Mississippi  River. 

-Census  Years 

1880         1890  1904  1910 

Northern  group 104.9         145.1         230.7        256.6 

Southern  group 48.8  79.7         117.5        132.3 

One  advantage  in  thus  expressing  the  question  is  that 
it  affords  a  suggestion  of  a  method  for  seeking  an  answer. 

A  number  of  circumstances,  such  as  availability  of  good 
statistics,  the  prevalence  of  high  social  standards,  the 
composition  of  the  population  which  is  in  certain  respects 
peculiar,  etc.,  combine  to  make  the  experience  of  the  state 
of  California  worthy  of  special  study  in  this  connection. 

The  growth  of  the  population  of  that  state  has  for  a 
number  of  decades  been  in  large  part  by  immigration  from 
other  states,  especially  those  east  of  the  Mississippi  River. 
This  fact  has  created  an  opportunity  of  making  a  compari- 
son such  as  we  desire  to  make,  in  order  to  find  an  answer 
to  the  question  that  is  before  us,  by  noting  the  number  of 
admissions  to  the  state  hospitals  of  California  contributed  by 
natives  of  the  above-mentioned  two  groups  of  states  who  have 
taken  up  their  residence  in  California. 

If  the  incidence  of  mental  disorders  differs  materially  in 
these  two  groups  of  states,  it  would  seem  that  the  difference 
should  be  revealed  by  this  comparison — one  that  is  made 


164  THE  PRACTICE  OF  PSYCHIATRY 

on  the  basis  of  a  standard  which,  though  not  to  be  theo- 
retically formulated,  is  nevertheless  fairly  definite,  uniform 
and  readily  applicable,  namely,  the  standard  of  the  pre- 
vailing environmental  conditions  of  California. 

During  the  biennial  period  ending  June  30,  1910,^  the 
natives  of  the  Northern  group  of  states  residing  in  California 
furnished  147.3  admissions  to  the  state  hospitals  of  California 
per  hundred  thousand  of  their  general  population.  During 
the  same  period  the  natives  of  the  Southern  group  of  states 
furnished  166.7  admissions  per  hundred  thousand:  a  differ- 
ence of  13.1%.  . 

In  other  words,  as  far  as  may  be  judged  from  these 
statistics,  the  Southern  states  east  of  the  Mississippi  River, 
which  have  had  for  many  years,  and  still  have,  poorer  and 
less  adequate  facilities  for  the  care  of  their  insane  than  the 
Northern,  now  show  a  higher  incidence  of  mental  disorders 
in  their  population. 

Thus  it  would  seem  that  the  much  greater  relative 
number  of  insane  in  institutions  in  the  Northern  group 
of  states  is  but  an  indication  of  a  more  thoroughly  carried 
out  policy  of  segregation,  and  appears  to  have  already  pro- 
duced a  demonstrable  eugenic  effect :  for  the  application  of  a 
common  standard  to  representative  portions  of  the  two  popu- 
lation groups  reveals  evidence  showing  that  the  incidence  of 
mental  disorders  is  actually  greater  in  the  Southern  group. 

Similarly,  it  would  appear  that  the  progressive  increase 
in  the  relative  number  of  institution  inmates,  observed 
throughout  the  country  during  the  past  several  decades, 
is  also  but  an  indication  of  more  thorough  segregation  which 
has,  in  all  probability,  been  attended  by  the  same  eugenic 
effect. 

The  conclusion  seems  justifiable,  then,  that  such  evi- 
dence as  is  available,  far  from  showing  that  mental  dis- 
orders are  on  the  increase,  tends  to  show  rather  that  they 
are  on  the  decline. 

1  Seventh  Biennial  Report  of  the  State  Commission  in  Lunacy  of 
CaUfornia. 


CHAPTER    XII 

THE  PRACTICE  OF  PSYCHIATRY  (Continued) 
PROPHYLAXIS    IX    PSYCHIATRY  ^ 

RELATIONSHIP  BETWEEN  BAD  HEREDITY  AND  OTHER 
CAUSES— PREVENTION  OF  BAD  HEREDITY— PREVEN- 
TION OF  ALCOHOLISM,  DRUG  ADDICTIONS,  AND  SYPH- 
LIS—THE  INDI VID  UAL—IMMIGRA  TION 

As  stated  in  the  chapter  on  etiology,  amongst  the  many 
causes  of  mental  disease  may  be  distinguished  some  few 
that  are  essential  from  others  that  are  merely  incidental  or 
contributing. 

There  are  few  persons,  if  indeed  there  are  any,  who  are 
so  fortunate  as  to  go  through  life  without  being  repeatedly 
subjected  to  the  influence  of  some  of  the  incidental  causes: 
the  prevention  of  mental  disorders  will  consist  largely  in 
measures  for  combating  the  essential  causes — heredity, 
alcohol  and  drug  addictions,  syphilis,  and  head  injuries. 

Measures  for  the  prevention  of  mental  disorders  may  be 
undertaken  by  the  mdividual  or  by  society.  As  far  as 
the  average  healthy  individual  is  concerned  the  measures 
are  few  and  simple;  it  must,  however,  be  noted  as  a  fact 
which  has  been  repeatedly  demonstrated  under  the  most 
varied  conditions,  that  the  great  mass  of  individuals,  even 
if  made  fully  aware  of  all  dangers,  will  not  practice  pre- 
ventive measures  in  any  systematic  manner;  this  is  perhaps 
due  to  a  curious  trait  of  human  nature  owing  to  which  m.en 
are  disinclined  to  believe  that  any  evil  may  befall  them 
and  therefore  have  a  tendency  to  take  chances;    further 

1  A.  J.  Rosanoff.  Causes  and  Prevention  of  Insanity.  The  Long 
Island  Med.  Journ.,  Sept.,  1915. 

165 


166  THE  PRACTICE  OF  PSYCHIATRY 

it  must  be  remembered  that  the  great  causes  of  mental 
disorders  appear  in  the  shape  of  strong  temptations  which  are 
difl&cult  and  for  some  impossible  to  resist.  However  this 
may  be,  those  who  are  concerned  with  the  problems  of 
prophylaxis  in  psychiatry  would  be  impractical  if  they 
relied  entirely  upon  dissemination  of  knowledge  on  this 
subject  among  the  people  with  the  hope  of  thus  reducing  to 
a  material  extent  the  incidence  of  mental  disorders.  Dis- 
semination of  knowledge  should,  we  believe,  be  regarded 
as  a  preliminary  step  which  will  make  possible  the  applica- 
tion of  large  measures  bj?-  society  as  a  whole — for  nothing 
short  of  such  measures  will  constitute  an  effective  system 
of  mental  hygiene. 

Relationship  between  Bad  Heredity  and  Other  Causes. 
— The  prevention  of  had  heredity  affords  a  hope  of  reducing 
not  only  the  constitutional  mental  disorders,  but  also 
those  which  develop  on  the  basis  of  alcohol  and  drug  addic- 
tions and  of  syphilis,  as  may  be  judged  from  the  following 
considerations. 

As  regards  alcoholic  psychoses,  it  is  not  sufficient  to  know 
that  they  result  from  intemperance.  In  order  to  be  able 
to  deal  properly  with  the  problem  of  prevention  an  answer 
must  be  sought  to  the  question.  Why  do  some  persons 
drink  alcohol  in  injurious  quantities? — The  general  view  is 
that  initiation  into  habits  of  intemperance  occurs  as  a  result 
of  convivial  customs  or  through  bad  associations,  and  that 
in  such  ways  a  craving  is  established  which  leads  to  the 
development  of  chronic  alcoholism.  This  is  truth,  but  not 
the  whole  truth;  for  in  the  midst  of  the  same  social  condi- 
tions, favorable  or  unfavorable,  it  is  as  certain  that  some 
persons  will  become  alcoholic  as  it  is  that  others  will  not. 
The  difference  is  between  the  persons. 

During  the  fiscal  year  ending  September  30,  1914,  56 
cases  of  alcoholic  psychoses  were  admitted  to  the  Kings 
Park  State  Hospital;  in  18  of  these  data  concerning  heredity 
and  mental  make-up  of  the  patients  were  unascertained; 
of  the  remaining  38  cases  no  less  than  31  presented  either  a 


PROPHYLAXIS  IN  PSYCHIATRY  167 

neuropathic  family  history,  or  an  originally  inferior  mental 
make-up,  or  both;  and  only  7  gave  a  negative  personal  and 
family  history. 

The  conditions  under  which  such  hospital  statistics  are 
compiled  as  a  rule  give  rise  to  error  in  but  one  direction, 
namely,  in  the  direction  of  omitting  pertinent  facts  of 
family  or  personal  history;  thus  tending  to  lead  to  an 
underestimation  of  the  case  from  this  point  of  view.  Con- 
sidering this,  the  remarkable  showing  of  the  figures  must 
give  one  the  feeling  that  the  tendency  to  drink  alcohol  in 
amounts  sufficient  to  produce  mental  disease  is  largely  a 
neuropathic   manifestation. 

A  study  of  this  subject,  made  by  Dr.  D.  Heron  ^  and 
published  recently  from  the  Galton  Laboratory  of  Eugenics 
at  the  University  of  London,  has  yielded  a  similar  conclu- 
sion: "We  are  on  fairly  safe  ground  in  asserting  that  the 
relation  between  inebriety  and  mental  defect  is  about  0.76. 
We  have  thus  reached  a  definite  measure  of  a  relationship 
on  which  every  authority  on  alcoholism  has  laid  the  greatest 
possible  stress."  "  On  the  one  hand,  mental  condition  is 
usually  regarded  as  being  directly  affected  by  alcoholic 
excess,  and  on  the  other  hand  the  extent  of  the  individual's 
education  is  very  largely  determined  by  causes  which  are 
pre-alcoholic ;  yet  we  find  here  that  there  is  a  close  relation- 
ship between  the  two  characters,  and  this  is  strongly  in  favor 
of  the  view  that  the  defective  mental  condition  of  these 
inebriates,  like  the  extent  of  their  education,  is  pre-alcoholic 
and  that  the  alcoholism  flows  from  a  pre-existing  mental 
defect,  not  the  mental  defect  from  the  alcoholism."  "  All 
this  lends  support  to  the  view  that  the  mental  defect  of 
the  inebriate  is  not  an  actual  growth;  it  is  born,  not  bred; 
that  '  inebriety  is  more  an  incident  in  the  life  of  the  inebriate 
than  the  cause  of  his  mental  defect.'  " 

What  has  been  said  about  alcoholism  applies  with 
equal  force  to  di'iig  addictions. 

1  Eugenics  Laboratory  Memoirs,  xvii:  A  Second  Study  of  Extreme 
Alcoholism  in  Adults.     London,  1912, 


168  THE  PRACTICE  OF  PSYCHIATRY 

As  regards  syphilis,  in  this  connection,  it  is  necessary 
to  consider  before  all  the  manner  in  which  it  is  spread  so 
widely  through  the  population. 

Syphilitic  infection,  as  is  well  known,  may  be  of  non- 
venereal  as  well  as  of  venereal  origin.  Thus,  of  887  cases 
reported  by  Fournier/  45  were  of  non-venereal  origin, 
among  these  being  cases  of  inherited  syphilis,  of  infection 
of  wet-nurses  by  sucklings,  midwives  by  women  in  labor, 
etc.  Of  the  cases  of  venereal  origin,  not  all  result  from 
immoral  relations.  Thus  Fournier  -  estimates  that  of  all 
cases  in  women  the  infection  in  19%  is  acquired  by  married 
women  from  their  husbands.  But  even  in  cases  in  which 
the  infection  is  acquired  innocentlj^,  it  can  usually  be  traced 
indirectly  to  immoral  sexual  relations,  particularly  to 
prostitution,  as  its  original  source. 

The  prevention  of  sj^philis  and  with  it  of  psychoses  of 
sj^philitic  origin  is,  therefore,  closely  linked  to  the  prevention 
or  control  of  prostitution. 

To  what  extent  can  prostitution  be  controlled? 

First  of  all,  it  must  be  noted  that  at  no  time  has  any 
state  or  nation  as  yet  succeeded  in  abolishing  prostitution, 
and  as  late  as  1902  a  Committee  of  Fifteen  organized  in  New 
York  for  the  purpose  of  investigating  the  social  evil,  were 
led  in  their  report  to  express  the  view  that  the  summary 
extirpation  of  prostitution  "  in  the  present  state  of  the 
moral  evolution  of  the  race,  is  as  yet  impossible."  ^ 

Since  that  time,  however,  important  additions  have  been 
made  to  our  knowledge  of  prostitution,  so  that  to-day  the 
case  no  longer  seems  so  hopeless.  The  most  significant 
contribution  consists  in  the  discoveiy  of  the  close  relation- 
ship existing  between  prostitution  and  feeble-mindedness 
and  other  mental  disorders. 

This  relationship  has  been  carefully  studied  by  a  special 

^  Fournier.  The  Treatment  and  Prophylaxis  of  Syphilis.  English 
translation  by  C.  F.  Marshall.     New  York,  1907.     P.  348. 

2  Loc.  cit.,  p.  351. 

3  The  Social  Evil.     New  York,  1902.     (G.  P.  Putnam's  Sons)  P.  178. 


PROPHYLAXIS  IN  PSYCHIATRY  169 

commission  created  for  that  purpose  by  an  act  of  the  House 
of  Representatives  of  the  State  of  Massachusetts.^  We 
would  quote  the  following  from  their  highly  interesting 
official  report: 

"The  women  examined  were  in  three  groups:  young  girls  under 
sentence  in  the  State  Industrial  School  for  Girls,  the  House  of  Refuge, 
and  the  Welcome  House;  those  just  arrested  and  awaiting  trial  in  the 
Suffolk  House  of  Detention  in  Boston;  women  serving  sentence  in  the 
State  Reformatory  for  Women,  the  Suffolk  County  Jail,  and  the 
Suffolk  House  of  Correction. 

"  These  three  groups  represent  the  young  girls  who  have  just 
begun  prostitution,  the  women  plying  their  trade  on  the  streets  at 
the  present  time  and  the  women  who  are  old  offenders.  The  houses  of 
prostitution,  lodging  houses,  hotels  and  cafes  named  by  these  women 
as  the  places  where  they  plied  their  trade  are  the  same  as  those  noted 
by  the  field  investigators  employed  by  the  commission. 

"  The  Binet  tests  were  applied  to  289  of  the  300  women  examined, 
and  other  psj^chological  tests  were  used  in  doubtful  cases. 

"Of  the  300  prostitutes,  154,  or  51%  were  feeble-minded  and  11, 
or  3%  were  insane.  All  doubtful  cases  were  recorded  as  normal.  The 
mental  defect  of  those  154  women  was  so  pronounced  and  evident 
as  to  warrant  the  legal  commitment  of  each  one  as  a  feeble-minded 
person  or  as  a  defective  delinquent.  At  the  INIassachusetts  School 
for  the  Feeble-minded  there  are  an  equal  number  of  women  and  girl 
inmates,  medically  and  legally  certified  as  feeble-minded,  who  are  of 
equal  or  superior  mental  capacity. 

"  The  135  women  designated  as  normal  as  a  class  were  of  distinctly 
inferior  intelligence.  More  time  for  study  of  these  women,  more 
complete  histories  of  their  life  in  the  community  and  opportunity  for 
more  elaborate  psychological  tests  might  verify  the  belief  that  many  of 
them  also  were  feeble-minded  or  insane. 

"  Some  of  the  women  seen  at  the  Detention  House  were  so  under 
the  influence  of  drugs  or  alcohol  as  to  make  it  impossible  to  study  their 
mental  condition.  Others  at  the  Detention  House  and  in  the  prisons 
had  used  alcohol  to  excess  for  years,  and  in  the  time  available  it  was 
impossible  to  differentiate  between  alcoholic  deterioration  amd  mental 
defect.  These  drunken,  alcoholic  and  drug-stupefied  women  were 
all  recorded  as  normal. 

"  Of  the  135  women  rated  as  normal,  only  a  few  ever  read  a  news- 

^  Report  of  the  Commission  for  the  Investigation  of  the  White 
Slave  Traffic,  so-called.  February,  1914.  House,  No.  2281,  State 
of  Massachusetts. 


170  THE  PRACTICE  OF  PSYCHIATRY 

paper  or  a  book,  or  had  any  real  knowledge  of  current  events,  or  could 
converse  intelligently  upon  any  but  the  most  trivial  subjects.  Not 
more  than  six  of  the  entire  number  seemed  to  have  really  good  minds. 

"  It  has  long  been  held  that  prostitution  always  has  existed  and 
always  will  exist,  and  that  all  remedies  will  be  ineffective  and  of  no 
avail,  because  it  represents  a  variation  of  the  most  fundamental  human 
instinct. 

"  Recent  studies  of  prostitution  and  prostitutes  in  other  cities, 
states,  and  countries,  and,  in  connection  with  this  investigation,  the 
study  and  analysis  of  300  prostitutes  individually  examined  for  the 
commission,  the  observation  of  prostitutes  and  prostitution,  and 
of  the  immoral  young  girls  who  have  not  entered  prostitution  in  cities 
and  towns  all  over  the  State,  have  convinced  the  commission  that  this 
evil  is  susceptible  of  successful  attack  and  treatment.  The  fact  that 
one-half  of  the  women  examined  were  actually  feeble-minded  clears 
the  way  for  successful  treatment  for  this  portion  of  this  class.  The 
mental  status  of  the  prostitutes  under  arrest  should  be  determined,  and 
such  of  them  as  are  found  to  be  feeble-minded  or  defective  delinquents 
should  be  placed  under  custodial  treatment.  Thus  would  these  women 
themselves  be  saved  from  an  evil  fate,  pimps  and  procurers  would  lose 
their  willing  prey,  and  a  non-self-supporting  class  who  find  in  prostitu- 
tion their  only  way  of  earning  a  hving  would  be  taken  out  of  the  com- 
munity. 

"  The  recognition  of  feeble-minded  girls  at  an  early  age  in  the 
public  schools,  and  proper  provision  for  their  protection  in  the  com- 
munity or  custodial  care  in  an  institution,  would  prevent  much  of  the 
observed  immorality  among  young  girls  and  the  resulting  tempta- 
tions to  boys.  Precocious  sex  interests  and  practices  are  well-known 
symptoms  of  feeble-mindedness." 

The  situation,  then,  may  be  summarized  as  follows: 
at  least  three-fourths  of  all  cases  of  mental  disorders  occur 
on  the  basis  of  bad  heredity,  alcoholism,  drug  addictions,  or 
syphilis;  an  individual  who  is  of  normal  ancestry,  abstains 
from  alcohol  and  habit  forming  drugs  and  remains  free  from 
syphilitic  infection  is  not  seriously  threatened  with  a  mental 
disorder.  But  since  alcoholism  and  syphilis  are,  in  their 
turn,  so  generally  connected  either  directly  or  indirectly 
with  inherent  mental  defectiveness,  it  follows  that  heredity 
is,  as  long  taught  with  characteristic  clearness  of  thought 
and  diction  by  the  French  school  of  psychiatry,  the  cause  of 
causes  of  mental  disorders. 


PROPHYLAXIS  IN  PSYCHIATRY  171 

It  may  safely  1)G  said,  therefore,  that  a  movement  for  the 
prevention  of  mental  disorders  will  lead  the  race  in  no  mistaken 
path  if  it  concentrates  the  hulk  of  its  energies  on  the  problem  of 
had  heredity. 

Prevention  of  Bad  Heredity. — The  means  that  have  been 
suggested  for  combating  l^ad  heredity  are  legal  restriction 
of  marriage,  surgical  sterilization,  and  segregation.  This 
would,  perhaps,  hardly  be  the  place  for  a  full  discussion  of 
the  advantages  and  disadvantages  of  these  measures; 
nor  is  it  to  be  assumed  that  any  one  of  them  is  to  be  adopted 
necessarily  to  the  complete  exclusion  of  the  others.  Suffice 
it  to  say  here  that  the  main  drawback  of  marriage  laws  in 
this  connection  is  their  ineffectiveness;  ^  and  that  to  steriliza- 
tion there  are  moral,  religious,  legal,  and  even  scientific 
objections  which  render  it  largely  unacceptable  to  public 
opinion.  On  the  other  hand,  segTegation,  though  also 
opposed  by  some,  is  evidently  much  more  generally  accept- 
able, as  is  shown  by  the  fact  that,  quite  independently  of 
any  consciously  eugenic  movement,  its  practice  has  made 
great  headwaj^  during  the  past  several  decades. 

We  may  conclude,  therefore,  that,  unlike  other  eugenic 
measures  that  have  been  proposed,  segregation  is  an  old 
practice  which  has  been  tried  out  everj'-where  and  to  which 
no  effective  objections  have  been  raised  either  on  rehgious, 
legal,  or  humanitarian  grounds;  it  has  had  of  late  a  remark- 
able growth;  and  it  may  be  anticipated  that  with  the 
growth  of  urban  centers,  progress  in  popular  education. 
improvement  of  methods  of  financing,  and  the  rise  in  stand- 
ards of  institution  care  will  come  vast  possibilities  of  further 
growth.^ 

If  mental  disorders  are  to  so  large  an  extent  a  heritage  from 

^  Adolf  Meyer.  The  Right  to  Marry.  What  Can  a  Democratic 
Civilization  Do  About  Heredity  and  Child  Welfaref  The  Survey, 
^'ol.  xxxvi,  No.  10.     Re-published  in  Mental  Hygiene,  Jan.,  1919. 

^  A.  J.  Rosanoff.  A  Study  of  Eugenic  Forces:  Particularly  of 
Social  Conditions  which  Bring  about  the  Segregation  of  Neuropathic 
Persons  in  Special  Institutions.     Amer.  Journ.  of  Insanity,  Oct.,  1915. 


172  THE  PRACTICE  OF  PSYCHIATRY 

past  generations,  resulting  from  untold  centuries  of  neglect 
of  segregation;  and  if  the  very  incomplete  segregation  that 
has  been  practiced  in  but  two  or  three  generations  can  already 
be  shown  to  have  made  an  impression  on  this  ancient  problem 
(see  p.  164) ;  then  it  would  seem  that  we  have  at  last  arrived 
at  a  point  where  we  need  to  consider  but  ways  and  means; 
for  we  are  in  a  position  to  say  to  the  people  and  to  legisla- 
tures, Mental  health  is  purchasable;  the  prevalence  of  mental 
disorders  can  he  reduced  for  coming  generations  with  the  aid 
of  dollars  and  cents  spent  for  segregation  in  this  generation. 

In  discussing  the  feasibility  of  segregation  the  questions 
are  often  raised,  What  persons  should  be  selected  for  segre- 
gation? How  should  the  selection  be  made?  How  can  errors 
be  avoided? — The  implication  is  that,  inasmuch  as  it  is  not 
possible  to  sharply  distinguish  mentally  abnormal  from 
normal  persons,  segregation  might  in  practice  entail  much 
arbitrariness  and  injustice. 

The  answer  is  that  these  questions  are  purely  academic; 
in  practice  they  do  not  arise  in  any  troublesome  manner. 
For  instance,  out  of  a  total  of  8700  cases  admitted  to  the 
New  York  State  hospitals  during  the  year  ending  June  30, 
1918,  96  were  eventually  classified  as  "  Not  insane."  These, 
however,  were  thus  classified  not  because  they  presented  no 
mental  abnormality,  but  because  their  abnormality  was  of 
such  nature  as  not  to  be  included  within  the  statutory  defini- 
tion of  cases  entitled  to  treatment  in  state  hospitals.  They 
were  further  classified  as  follows :  ^ 

TABLE  7. 

Not  insane,  epilepsy 2 

alcoholism 22     _ 

drug  addiction 6 

constitutional  psychopathic  inferiority ...   17 

mental  deficiency 19 

others 30 

1  Thirtieth  Annual  Report  of  the  N.  Y.  State  Hospital  Commission, 
Albany,  1919. 


PROPHYLAXIS  IN  PSYCHIATRY  173 

The  experience  of  institutions  for  the  feeble-minded, 
epileptic,  and  inebriate  has  been  the  same. 

Moreover,  there  are  many  safeguards  in  the  practice  of 
segregation  to  rectify  errors  made  in  rare  cases.  The  ad- 
mission of  a  patient  to  an  institution  is  not  an  irrevocable 
step.  It  is  but  the  beginning  of  a  more  intensive  investi- 
gation, observation  and  treatment  of  his  case,  the  object 
of  which  is  to  help  him,  if  possible,  to  such  a  readjustment 
as  would  enable  him  to  return  to  normal  life  again.  Through 
a  liberal  parole  system  he  is  given  opportunities  of  trying  life 
outside  again  under  the  most  favorable  conditions  of  super- 
vision, employment,  and  assistance  that  could  be  created 
for  hhn.  Under  such  conditions  many  patients  are  after  a 
short  time  discharged  from  institutions.  If  eventually, 
after  repeated  trials  of  this  kind,  the  patient  has  to  return 
to  the  institution  for  permanent  segregation,  it  is  not  because 
a  certain  diagnosis  of  mental  disorder  has  been  made;  or 
because  someone,  however  expert,  has  judged  him  to  require 
segregation ;  but  because  the  need  of  segregation  in  his  case 
has  forced  itself  to  recognition  by  a  full  demonstration  of 
his  utter  incapability  of  achieving  a  social  adjustment. 

To-day  the  great  obstacle  to  more  complete  segregation 
is  to  be  found  not  in  any  difficulty  of  selection.  The  obstacle 
is  an  economic  one,  limiting  the  states'  facilities  for  segrega- 
tion. Not  even  the  most  progressive  states  possess  as  yet 
adequate  institutional  capacity.  "  Thus,  the  State  of  New 
York  had,  according  to  the  Thirteenth  U.  S.  Census  in  1910, 
institutional  provision  for  396.3  insane,  epileptic,  and 
mentally  defective  persons  per  100,000  of  its  total  popula- 
tion. In  Nassau  County  it  was  estimated  that  816.7  persons 
per  100,000  of  total  population  require  institutional  cus- 
tody." 1 

It  will  be  judged,  from  what  has  already  been  said, 
that   the   proposal   to    extend   the   scope  and  practice   of 

1  A.  J.  Rosanoff.  Survey  of  Mental  Disorders  in  Nassau  County, 
N.  Y.  Report  published  by  The  National  Committee  for  Mental 
Hygiene,  New  York,  1917. 


174  THE  PRACTICE  OF  PSYCHIATRY 

segregation  does  not  imply  the  forced  segregation  of  every 
person  in  whom  the  existence  of  a  neuropathic  condition 
might  be  estabhshed  by  medical  diagnosis.  It  is  well  known 
that  grave  neuropathic  conditions,  notably  manic-depressive 
psychoses  and  epilepsy,  are  not  incompatible  with  the  highest 
degree  of  intellectual  efficiency.  As  striking  instances  might 
be  mentioned  the  cases  of  William  Cowper,  the  English 
poet,  who  suffered  from  many  severe  manic-depressive 
attacks;  Julius  Robert  Mayer,  the  physicist  and  discoverer 
of  the  principle  of  conservation  of  energy,  who  was  similarly 
afflicted;  and  Gustave  Flaubert,  the  great  French  novelist, 
who  suffered  from  epilepsy.^ 

Not  insanity,  epilepsy,  or  mental  deficiency,  as  such, 
but  lack  of  capacity  for  social  adjustment  is  the  proper  basis 
for  segregation. 

Prevention  of  Alcoholism,  Drug  Addictions,  and  Syphilis. 
— Direct  efforts  for  the  prevention  of  alcoholism,  drug 
addictions,  and  syphilis,  independently  of  the  nieasures  for 
combating  bad  heredity,  are  by  no  means  to  be  neglected. 

Abstinence. — The  most  trustworthy  experimental  data 
seem  to  show  that  even  moderate  indulgence  in  alcohol, 
though  producing  in  the  subject  a  sense  of  well-being  and  of 
increased  physical  and  mental  ability,  in  reality  causes  im- 
pairment of  muscular  power  and  coordination  and  of  men- 
tal efficiency .2  In  persons  of  neurotic  constitution  com- 
paratively slight  indulgence  often  causes  severe  mental 
disturbance. 

1  A.  J.  Rosanoff.  Intellectual  Efficiency  in  Relation  to  Insanity. 
Amer.  Joiirn.  of  Insanity,  July,  1916. 

2  L.  Schneider.  Alkohol  und  Muskelkraft.  Pflvigers  Arch.  f.  d. 
ges.  Physiol.,  Vol.  xciii,  p.  451. — M.  Mayer.  Ueber  die  Beeinflussung 
der  Schrift  durch  den  Alkohol.  Kraepelins  Psychol.  Arb.,  Vol.  Ill, 
p.  635. — G.  Aschaffenburg.  Praktische  Arbeit  unter  Alkoholwirkung. 
Kraepelins  Psychol.  Arb.,  Vol.  I,  p.  608. — A.  Smith.  Ueber  die  Beein- 
flussung einfacher  psychischer  Vorgdnge  durch  chronische  Alkoholvergif- 
tung.  Br.  lib.  d.  V.  intern.  Kongr.  z.  Bekampf.  d.  Missbr.  geist. 
Getranke.  Basel,  1896,  p.  341. — E.  Kiirz  and  E.  Kraepelin.  Ueber 
die  Beeinflussung  psychischer  Vorgdnge  durch  regelmdssigen  Alkoholismus. 
Kraepelins  Psychol.  Arb.,  Vol.  Ill,  p.  417. 


PROPHYLAXIS  IN  PSYCHIATRY  173 

Those  who  favor  temperance  rather  than  abstinence  do 
so  mainly  on  the  basis  of  the  usefulness  of  alcohol  as  a  food 
and  as  a  sedative  contributing  to  the  recuperative  effect  of 
rest  by  promoting  complete  relaxation.  It  is  not  to  be 
disputed  that  alcohol  does  possess  these  beneficial  qualities, 
but  it  is  for  many  not  possible  to  derive  the  benefit  and  yet 
escape  the  harm  from  using  it.  Moreover,  moderate  indul- 
gence, if  regular,  leads  but  too  often  to  the  development  of 
uncontrollable  craving,  increase  of  dosage,  and  ultimately 
to  chronic  alcohoHsm.  It  need  hardly  be  added  that  alcohol 
either  as  a  food  or  as  a  sedative  is  not  a  physiological  neces- 
sity. 

Therefore  the  advice  of  the  physician  to  his  patient  must 
usually  be:   total  abstinence  ivithout  compromise. 

Of  measures  that  may  be  employed  by  society  the  most 
important  is  dissemination  of  the  knowledge  of  the  true  effect 
of  alcohol,  which  should  constitute  a  part  of  the  program 
of  all  pubHc  schools.  It  is  necessary  before  all  to  dispel  the 
prevailing  notions  that  alcohol  is  harmful  only  when  taken 
in  excess  and  that,  taken  in  moderation,  it  is  beneficial  and 
even  necessary  to  the  laborer  or  artisan. 

The  next  in  importance  are  legislative  measures.  As 
having  been  actually  proved  to  be  in  some  degree  effective 
may  be  mentioned:  (1)  The  Gothenburg  system,  (2)  pro- 
hibition, and  (3)  local  option. 

The  Gothenburg  system  was  first  instituted  in  Sweden, 
and  has  since  been  adopted  by  Norway  and  Finland.  The 
Swedish  Law  of  1855  gives  to  each  municipality  the  right  of 
prohibiting  within  its  jurisdiction  the  sale  of  liquor  over  the 
bar  or  in  stores  in  quantities  under  forty  liters.  Retail 
licenses  in  hmited  number — according  to  population — are 
awarded  by  the  municipal  authorities  at  pubhc  sale  to  the 
highest  bidder,  provided  he  be  a  person  of  good  reputation. 
The  law  provides  further  that  retail  licenses  may  be  awarded 
to  societies,  thus  making  it  possible  for  public-spirited  citizens 
to  form  organizations  for  the  purpose  of  securing  the  licenses 
which  are  at  the  disposal  of  the  municipal  authorities  and 


176  THE  PRACTICE  OF  PSYCHIATRY 

thus  assuming  control  of  the  entire  retail  liquor  trade. 
Thus  was  founded  for  the  first  time  in  the  city  of  Gothen- 
burg "  The  Gothenburg  Eetail  Liquor-  Stock  Company." 
This  and  other  similar  companies  derive,  of  course,  no  profit 
from  the  trade,  the  profits  going  in  part  (60-80%)  into 
the  city  treasury  and  in  part  (20-40%)  into  the  state 
treasury.  The  aim  of  such  companies,  in  contrast  with 
that  of  private  liquor  dealers,  is  to  reduce  the  con- 
sumption of  liquors;  for  that  purpose  they  have  established 
popular  price  restaurants,  reading  rooms,  etc.,  for  working 
people. 

The  results  of  this  legislation  may  be  judged  from  the 
following  statistics.^ 

Prior  to  1855  liquor  could  be  purchased  in  Sweden  in  any 
hamlet.  In  1869  there  was  only  one  barroom  or  liquor  store 
to  8,028  inhabitants;  in  1880  only  one  to  13,450  inhabitants. 

There  are  2400  separate  municipalities  in  Sweden;  of 
these  1800  have  entirely  abolished  barrooms  and  retail 
liquor  stores. 

The  consumption  of  liquor  in  Sweden  in  1824  was  46 
liters  per  capita,  in  1851  it  was  22  Uters,  and  in  1896  it  had 
become  reduced  to  7.2  liters. 

Prior  to  enactment  of  the  laws  of  1855  from  25%  to 
30%  of  all  male  cases  admitted  to  hospitals  for  the  insane 
were  due  to  intemperance.  Following  the  enactment  of 
those  laws  this  percentage  gradually  became  less,  and  from 
1865  until  1899  it  varied  between  5.2%  and  7.19%. 

Prohibition  has  been  tried  in  several  states.  In  some 
of  these  states  the  prohibition  laws  have  been  repealed 
(Connecticut,  Vermont,  Massachusetts) ;  in  others  they  have 
been  but  recently  enacted  (Alabama,  Georgia,  Oklahoma); 
in  still  others  they  have  been  in  force  for  many  years  (in 
Maine  since  1851,  in  Kansas  since  1880,  in  North  Dakota 
since  1889),  so  that  they  may  be  assumed  to  have  been 
given  a  thorough  practical  trial. 

^  A.  Baer  and  B.  Laquer.  Die  Triuiksucht  und  ihre  Abwehr.  Berlin 
and  Vienna,  1907. 


PROPHYLAXIS  IN  PSYCHIATRY 


177 


Practical  difficulties  of  enforcing  state  prohibition  laws 
reduce  materially  the  possible  effectiveness  of  such  laws. 

Nevertheless  it  has  been  amply  shown  that  crime  and 
pauperism  have  been  reduced  wherever  prohibition  laws  have 
been  enacted.^ 

The  effect  of  no  license  under  local  option  is  similar 
to  that  of  prohibition;  that  is  to  say,  drunkenness,  crime, 
and  pauperism  are  undoubtedly  reduced,  but  the  incidence 
of  insanity  is  but  slightly,  if  at  all,  affected. 

The  following  table  shows  the  reduction  of  drunkenness 
which  resulted  from  no  license  under  local  option  in  several 
cities  in  Massachusetts. 

TABLE  8. 


Cities. 


Brockton. .  . . 

Waltham. .  .  . 
Taunton. . . . 

Chelsea 

Newburyport 

Lowell 

Salem 

Woburn 

Fitchburg.  .  . 


Arrests  for  Drunkenness. 


License. 


Year. 


1898 

1900 

1901 

1902 

1901- 

1902 

1903 

1903 

1905 


Number 
of  Ar- 
rests. 


1627 

634 

1202 

1246 

673 

4077 

1432 

842 

1160 


No  License. 


Year. 


1899 
1901 
1900 
1901 
1902 
1903 
1904 
1904 
1906 


Number 
of  Ar- 
rests. 


455 
179 
482 
398 
150 
2304 
503 
204 
359 


It  would  be  too  early  as  yet  to  size  up  the  effects  of  the 
more  recently  enacted  national  prohibition. 


1  Year  Book  of  the  Anti-Saloon  League,  1908. — Twenty-sixth 
Annual  Report  of  the  Massachusetts  Bureau  of  Labor.  Boston,  1896. 
— Twenty-seventh  Annual  Report  of  the  Massachusetts  State  Board 
of  Charities,  1907. 


178  THE  PRACTICE  OF  PSYCHIATRY 

As  regards  drug  addictions,  the  solution  of  the  problem 
would  seem  to  be  simple  in  comparison  with  the  problem 
of  alcoholism.  No  considerable  opposition  would  be  en- 
countered to  legislation  which  would  make  the  importation, 
manufacture,  distribution,  and  sale  of  habit-forming  drugs 
a  monopoly  of  the  federal  government  and  which  would 
at  the  same  time  prohibit  any  unauthorized  traffic  in  them. 

It  seems  strange  that  in  the  world  campaigns  against 
syphilis  there  should  have  been  until  recently  complete 
neglect  of  measures  which  have  been  so  successful  in  the 
prevention  of  other  communicable  diseases,  namely,  the 
compulsory  reporting  of  all  cases,  regardless  of  the  manner 
or  source  of  infection,  and  their  hospitalization,  if  necessary, 
during  the  period  of  greatest  infectiousness. 

Local  inunction  with  calomel  ointment  applied  within 
an  hour  or  even  within  several  hours  of  exposure  to  the 
infection  may  prevent  the  development  of  syphilis.^ 

For  the  prevention  of  hereditary  syphilis  Fournier  gives 
the  following  rule:  "When  a  woman  is  pregnant  with  a 
child  threatened,  by  paternal  antecedents,  with  syphilitic 
heredity,  syphilitic  treatment  of  the  mother,  although 
healthy,  constitutes  for  this  child  a  real  and  powerful  safe- 
guard for  which  there  is  a  precise  and  formal  indication."  ^ 

Finally  there  can  be  no  doubt  that  in  cases  of  syphilitic 
infection  promptness  and  thoroughness  of  treatment,  until 
the  Wassermann  reaction  and  cerebro-spinal  fluid  findings 
become  and  remain  negative,  is  capable  of  greatly  reducing 
or  even  eliminating  the  danger  of  involvement  of  the  ner- 
vous system. 

Head  Injuries. — There  is  but  little  to  be  said  with 
reference  to  head  injuries  which,  like  other  injuries  resulting 

^  Articles  by  L.  W.  Harrison  and  C.  N.  Fiske  in  A  System  of  Syphilis, 
edited  by  Power  and  Murphy.  London,  1910.  Vol.  VI,  pp.  137  and 
308. — M.  F.  Gates.  The  Prophylaxis  of  Gonorrhoea.  The  Therapeutic 
Gazette,  Jan.,  1911. 

2  Fournier.  The  Treatment  and  Prophylaxis  of  Syphilis.  English 
translation  by  C.  F.  Marshall.     New  York,  1907.     P.  447. 


PROPHYLAXIS  IN  PSYCHIATRY 


179 


in  either  disability  or  death,  have  become  common  as  a 
result  of  the  great  modern  development  of  industries,  means 
of  transportation,  etc.  It  may  be  pointed  out,  however, 
that  in  the  United  States,  owing,  probably,  to  imperfect 
legislative  protection,  serious  accidents  are  needlessly 
frequent,  as  may  be  judged  from  the  example  furnished  by 
American  and  British  railroad  statistics.  These,  for  the 
year  1906,^  are  given  in  the  following  table: 

TABLE  9. 


American 

British 

Railroads. 

Railroads. 

Total  number  of  passengers  carried.  .  .  . 

800,000,000 

1,200,000,000 

Total  miles  of  track 

200,000 
13,455 

27,000 
239 

Number  of  collisions  and  derailments. .  . 

Number  of  passengers  killed 

146 

58 

Number  of  passengers  injured 

6,000 

631 

Number  of  employees  killed 

879 

13 

Number  of  employees  injured 

7,483 

140 

The  IndividuaL — It  has  already  been  said  that  an 
individual,  who  comes  from  normal  stock,  abstains  from 
alcohol  and  habit-forming  drugs,  is  free  from  syphilis,  and 
escapes  accidental  head  injury,  is  not  threatened  with  mental 
disorder. 

It  is  not  so  with  the  neuropathic  individual:  for  him 
every  feature  of  life  in  society  presents  possible  dangers. 
From  childhood  up  the  adjustment  between  him  and  his 
environment  must  be  nicely  controlled  if  the  danger  of  a 
mental  breakdown  is  to  be  minimized;  his  bringing-up  at 
home,  his  education  at  school,  his  sexual  life,  his  career,  his 
social  and  family  relations  are  great  matters  for  special 
adjustment,  particularly  with  the  ends  in  view  of  proper 
habit  training,  avoidance  of  the  incidental  causes  referred  to 
in  the  chapter  on  Etiology  as  possessing  quasi-specific  potency 

^  J.  O.  Fagan.  Confessions  of  a  Railroad  Signalman.  Boston  and 
New  York,  1908. 


180  THE  PRACTICE  OF  PSYCHIATRY 

in  the  production  of  mental  alienation,  and  prompt  institu- 
tion of  treatment  upon  the  appearance  of  any  symptoms. 

Immigration. — The  importance  for  this  country  of 
immigration  in  connection  with  the  problems  of  the  prev- 
alence and  prevention  of  mental  disorders  has  already  been 
pointed  out  in  the  chapter  on  Etiology.  Although  the  con- 
clusion has  been  drawn  that  there  is  no  evidence  to  show 
that  there  is  a  greater  proneness  toward  mental  disease 
in  the  foreign-born  than  in  the  native  population,  this  is  not 
to  be  construed  as  arguing  in  favor  of  relaxing  the  efforts 
of  keeping  out  all  mentally  defective  immigrants;  on  the  con- 
trary, whether  mental  disease  be  relatively  frequent  or  rare 
among  immigrants,  the  welfare  of  this  country  demands  that 
defective  persons  be  prevented  from  entering  and  remain- 
ing in  it  and  that  the  facilities  for  their  detection  and  de- 
portation be  perfected  and  increased  rather  than  reduced. 
On  the  other  hand,  a  policy  of  general  restriction  of  immi- 
gration, such  as  has  been  advocated  by  some,  would  seem 
to  be  unnecessary  and  unjustified  as  far  as  the  interests  of 
eugenics  and  mental  hygiene  in  this  country  are  concerned. 


CHAPTER  XIII 
THE  PRACTICE  OF  PSYCHIATRY  (Continued) 

COMMITMENT— LEGAL  COMPETENCE— TESTAMENTARY 
CAPACITY— CRIMINAL  RESPONSIBILITY— RELA TION- 
SHIP  BETWEEN  VICE,  CRIME  AND  MENTAL  DISORDERS 

Medico-Legal  Questions  in  Psychiatry. — The  most  im- 
portant medico-legal  questions  that  may  arise  in  connection 
with  cases  of  alleged  mental  disorders  are  those  of  necessity 
of  commitment,  competence  in  the  management  of  one's 
own  affairs,  testamentary  capacity,  and  criminal  responsi- 
bility. The  mere  fact  of  the  existence  of  a  mental  disorder, 
estabhshed  by  a  medical  diagnosis,  is  not  suflScient  to  settle 
these  questions. 

Commitment. — The  question  of  necessity  of  commit- 
ment has  already  been  touched  on.  The  tendency  in  leading 
states  is  to  limit  as  far  as  possible  the  practice  of  commit- 
ting cases,  allowing  any  suitable  case  to  be  admitted  to 
a  state  hospital  on  voluntary  application,  at  any  time, 
without  special  formality. 

Psychiatrists  are  looking  forward  to  even  greater  facility 
of  obtaining  treatment  for  cases  of  mental  disorders  in  the 
future  in  psychopathic  wards  to  be  established  in  connection 
with  general  hospitals:  "  The  details  of  transfer  from  the 
psychopathic  ward  to  the  large  state  institutions  should 
be  made  as  simple  as  possible.  Transfer  should  be  made 
effective  on  a  certificate  of  two  properly  qualified  physicians 
and  the  matter  should  not  have  to  come  into  court  at  all 
unless  it  is  brought  there  by  the  patient,  his  relatives, 
or  some  friends  on  his  behalf.  I  would  not  close  the  courts 
to  the  so-called  insane  by  any  means,  but  I  would  not  insist 

181 


182  THE  PRACTICE  OF  PSYCHIATRY 

on  a  legal  process,  whether  the  patient  wanted  it  or  not; 
I  would  not  insist,  so  to  speak,  on  cramming  an  alleged 
constitutional  right  down  the  patient's  throat  at  the  expense 
of  his  life.  We  see  to-day  this  process  of  commitment  going 
on  where  nobody  wants  it.  The  patient  does  not  want  it, 
the  patient's  friends  and  relatives  do  not  want  it,  and 
anybody  who  stands  and  watches  it  proceed  recognizes 
on  the  face  of  it  that  it  is  a  farce.  I  would,  therefore,  pro- 
ceed in  the  matter  of  commitment  in  the  simplest  way. 
Leave  the  courts  accessible  to  the  patient  if  he  wants  to 
appeal  for  relief,  and  it  will  be  surprising  how  rare  such 
appeals  will  be."  ^ 

Legal  Competence — Testamentary  Capacity. — As  regards 
competence  in  the  management  of  one's  own  affairs  and 
testamentary  capacity,  no  difficulty  is  experienced  in  the 
majority  of  cases  of  pronounced  mental  disorder;  difficulty 
is  met  with  rather  in  connection  with  milder  cases  in  which 
there  may  be  room  for  legitimate  difference  of  oyinion.  In 
cases  in  which  a  direct  examination  of  the  p^^rson  whose 
mentality  is  in  question  is  not  practicable,  the  opinion  of  a 
psychiatrist  is  of  but  little  more  value  than  that  of  a  lay 
person ;  in  such  cases  it  would  seem  best  to  place  the  burden 
of  proof  on  those  who  allege  incompetence  or  limited  testa- 
mentary capacity,  and  to  require  as  proof  not  merely  opinion, 
however  expert,  but  instances  of  actual  business  mismanage- 
ment of  obviously  abnormal  degree  or  nature.  Where  there 
is  opportunity  for  direct  examination  the  testimony  of  a 
psychiatrist  may  be  of  determining  value,  mainly  for  the 
reason  that  he  is  better  able  than  a  layman  to  establish 
or  eliminate,  as  the  case  may  be,  the  existence  of  defects  of 
memory,  judgment,  affectivity,  etc.,  which  would  have  a 
bearing  on  the  question  at  issue.  Here  again  facts,  as  re- 
vealed by  the  examination,  rather  than  opinions,  however 
expert,  will  be  of  greatest  assistance  to  the  judicial  authori- 
ties in  drawing  a  just  conclusion.     It  need  hardly  be  said 

^  Wm.   A.   White.     Dividing  Line   between   General   Hospital  and 
Hospital  for  Insane.     The  Modern  Hospital,  March,  1914. 


MEDICO-LEGAL  QUESTIONS  183 

that  here,  as  under  other  conditions,  the  testimony  of 
witnesses,  including  expert  witnesses,  is  of  value  according 
to  the  degree  of  freedom  from  bias.  It  is,  of  course,  not 
legal  for  a  court  to  rule  out  the  testimony  furnished  by 
witnesses  retained  either  by  the  plaintiff  or  by  the  defendant ; 
but  it  is  possible,  and  desirable  in  the  cause  of  justice,  for 
the  court  to  call  experts  in  order  to  be  sure  of  securing 
testimony  that  is  free  from  even  unconscious  bias. 

A  psychiatrist  called  as  an  expert  ought  by  right  to 
refrain  from  givmg  an  opinion  on  the  main  question  at 
issue,  that  of  competence  or  testamentary  capacity,  that 
being,  strictly  speaking,  not  a  medical  or  scientific  question 
at  all,  but  a  question  of  common  sense  for  the  court  to  deter- 
mine. The  data  revealed  by  his  examination  and  his 
judgment  of  their  pathological  significance  are  all  that  he  can 
contribute  as  an  expert;  an  opinion  on  competence  or  testa- 
mentary capacity  that  might  be  elicited  from  him  should 
not  be  considered  as  being  of  greater  value  than  one  offered 
by  anyone  else. 

Criminal  Responsibility. — Perhaps  the  most  difficult 
position  in  which  a  psychiatrist  may  find  himself  is  when 
he  is  consulted  on  the  question  of  criminal  responsibility. 
Here  the  difficulty  hes  not  so  much  in  the  nature  of  the 
question  as  in  the  difference  between  the  current  legal  and 
the  scientific  conceptions  of  responsibility. 

The  current  legal  cenception  is  based  on  the  meta- 
physical theory  of  freedom  of  the  will;  the  individual 
must  exercise  his  will  under  the  guidance  of  ethical  prin- 
ciples; he  is  responsible  for  his  acts  unless,  owing  to  im- 
maturity or  mental  disease,  he  is  incapable  of  distinguishing 
right  from  wrong  and  is  thus  bereft  of  proper  guidance; 
when  no  such  incapacity  can  be  shown  he  must  undergo 
punishment  in  proportion  to  the  gravity  of  his  crime;  this 
punishment  or  retribution,  which  is  nothing  but  a  systemati- 
zation  of  the  original  impulse  of  revenge,  is  now  most  fre- 
quently justified  as  a  deterrent  measure;  by  instilling  a 
fear  of  similar  punishment,  it  is  supposed,  society  protects 


184   •  THE  PRACTICE  OF  PSYCHIATRY 

itself  against  repetitions  of  the  crime;  under  the  Influence 
of  this  fear  responsible  persons,  i.e.,  those  capable  of  dis- 
tinguishing right  from  wrong,  will  refrain  from  doing  wrong. 

The  psychiatrist,  when  consulted  in  a  criminal  case,  is 
not  asked  to  state  in  a  general  way  whether  or  not  in  his 
opinion  the  accused  is  insane,  but  whether  he  is  insane  in 
the  special  legal  sense  with  reference  to  criminal  responsi- 
bility, i.e.,  incapable  of  distinguishing  right  from  wrong. 

The  scientific  conception  of  responsibility  is,  of  course, 
very  different;  the  metaphysical  theory  of  freedom  of  the 
will  has  no  place  in  science;  the  phenomena  of  the  will,  like 
other  natural  phenomena,  are  subject  to  natural  laws  and 
are  determined  by  antecedents,  such  as  heredity,  education, 
various  environmental  influences,  and  events  immediately 
preceding  a  given  act  under  consideration,  that  is  to  say, 
factors  for  the  most  part  beyond  the  control  of  the  individual; 
responsibihty,  therefore,  in  the  sense  of  liability  to  profitless 
suffering  in  retribution  for  wrongdoing,  does  not  exist  scien- 
tifically in  any  case,  sane  or  insane. 

On  the  other  hand,  everybody,  sane  or  insane,  is  respon- 
sible in  the  sense  of  being  liable  to  forfeit  his  liberty,  property, 
or  the  results  of  his  labor  when  necessary  for  the  protection 
of  the  rights  of  others  or  for  the  restoration  of  damage 
caused  by  him. 

It  is  true  that  the  tendency  of  modern  times  is  to  elimi- 
nate as  far  as  possible  the  element  of  retribution  in  the 
treatment  of  crime;  yet  the  object  of  a  court  proceeding  in  a 
criminal  case  is  to-day  still  the  determination  of  the  degree 
of  guilt  of  the  accused,  i.e.,  of  the  amount  of  punishment 
to  which  he  should  be  sentenced.  As  long  as  such  is  the  case, 
it  seems  to  us,  psyckiatrists  cannot  consistently  take  part  in 
the  proceeding.  They  can  assist  only  in  a  saentific  in- 
vestigation of  a  case  of  crime  for  the  purpose  of  determining 
its  complex  of  causes,  as  far  as  it  may  be  possible  to  do  so, 
and  of  thus  gaining  guidance  for  measures  of  prevention, 
such  as  temporary  or  permanent  segregation,  etc. 

The  object  of  the  court  proceeding,  from  such  a  point  of 


MEDICO-LEGAL  QUESTIONS  185 

view,  should  be  to  determine  whether  or  not  the  accased  has 
committed  the  crime  as  alleged  and,  if  so,  the  amount 
of  damage  as  well  as  it  can  be  estimated  in  terms  of  money 
value  and  the  extent  to  which  it  is  possible  for  the  damage 
to  be  made  good  either  by  attaching  the  property  of  the 
author  of  the  crime  or  by  a  judgment  against  the  products 
of  his  labor. 

The  scientific  attitude  in  relation  to  the  question  of 
criminal  responsibility  would  eliminate  the  incentives  for  the 
troublesome  plea  of  insanity  in  criminal  cases,  on  the  one 
hand,  by  ignoring  the  question  of  guilt  and,  on  the  other 
hand,  by  enforcing  a  responsibiUty  for  damage  in  all  cases, 
sane  or  insane. 

Relationship  between  Vice,  Crime,  and  Mental  Dis- 
orders.— The  almost  exclusive  preoccupation  of  criminal 
courts  with  the  question  of  guilt  and  punishment  has  led 
to  theu"  overlooking  largely  the  important  relationship  which 
there  is  between  vice  and  crime  and  mental  disorders.^ 
The  evidence  of  such  a  relationship  between  prostitution 
and  mental  defectiveness  has  already  been  given  in  the 
preceding  section  of  this  chapter,  in  connection  with  the  dis- 
cussion of  the  prophylaxis  of  syphilis. 

Equally  striking  is  the  evidence  of  the  relationship 
which  exists  between  mental  disorders  and  crime.  As 
regards  feeble-mindedness  alone,  for  instance,  Goddard  ^ 
cites  the  following  statistics  of  percentages  of  defectives 
found  in  various  reformatories  and  institutions  for  delin- 
quents by  the  systematic  application  of  Binet  tests:  Rah- 
way  Reformatory^,  New  Jersey,  46;  Geneva,  Illinois,  89; 
Ohio  Boj^s'  School,  70;  Ohio  Girls'  School,  70;  Virginia, 
three  reformatories,  79. 

The  statistics  of  the  United  States  Census  pertaining 
to  insanity  and  crime  are  also  of  interest  in  this  con- 
nection. 

1  A.  J.  Rosanoff.  A  Program  of  Psychiatric  Progress.  Med. 
Record,  Feb.  20,  1915. 

2  H.  H.  Goddard.     Feeble-mindedness.     New  York,  1914. 


186  THE  PRACTICE  OF  PSYCHIATRY 

The  States  of  this  country  may  be  divided  into  two 
groups  according  to  the  number  of  inmates  in  insane  hospitals 
in  proportion  to  the  general  population.  Since,  for  the 
present  purpose,  this  is  done  to  facilitate  the  study  of  the 
relationship  which  exists  between  crime  and  insanity,  it 
would  seem  best  to  take  into  consideration  only  the  male 
population  at  large  and  the  male  asylum  and  prison  inmates : 
crime  is  not  nearly  so  common,  whether  as  a  neuropathic 
manifestation  or  otherwise,  among  women  as  among  men, 
the  counterpart  among  women  being  sexual  immorality, 
prostitution,  illegitimacy,  etc. 

The  first  group  of  states,  comprising  Alabama,  Arkansas, 
Colorado,  Florida,  Georgia,  Idaho,  Louisiana,  Mississippi, 
New  Mexico,  North  Carolina,  North  Dakota,  Oklahoma, 
South  Carolina,  Tennessee,  Texas,  Utah,  West  Virginia,  and 
Wyoming,  has  a  total  male  population  10  years  of  age  or 
over  of  9,705,527;  each  of  these  states  has  less  than  200 
male  asylum  inmates  per  100,000  of  the  male  population 
10  years  of  age  or  over,  the  average  for  the  entire  group  being 
140.9. 

In  this  group  of  states  the  number  of  inmates  in  prisons, 
penitentiaries,  jails,  and  workhouses,  not  including  juvenile 
delinquents,  is  31,290,  i.e.,  322.4  per  100,000  of  the  general 
population  10  years  of  age  or  over. 

The  second  group  of  states,  comprising  Arizona,  Califor- 
nia, Connecticut,  Delaware,  Illinois,  Indiana,  Iowa,  Kansas, 
Kentucky,  Maine,  Maryland,  Massachusetts,  Michigan, 
Minnesota,  Missouri,  Montana,  Nebraska,  Nevada,  New 
Hampshire,  New  Jersey,  New  York,  Ohio,  Oregon,  Pennsyl- 
vania, Rhode  Island,  South  Dakota,  Vermont,  Virginia, 
Washington,  and  Wisconsin,  has  a  total  male  population 
10  years  of  age  or  over  of  27,190,148;  each  of  these  states 
has  more  than  200  male  asylum  inmates  per  100,000  of  the 
male  population  10  years  of  age  or  over,  the  average  for  the 
entire  group  being  304.7. 

In  this  group  of  states  the  number  of  inmates  in  prisons, 
penitentiaries,  jails,  and  workhouses,  not  including  juvenile 


MEDICO-LEGAL  QUESTIONS  187 

delinquents,  is  71,482,  i.e.,  262.9  per  100,000  of  the  general 
population  10  years  of  age  or  over. 

The  contrast  between  the  two  groups  of  states  as  regards 
the  relative  number  of  prisoners  is  sufficiently  striking  as 
revealed  by  the  census  statistics.  But  it  is  probable  that  the 
excess  of  crime  in  the  first  group  of  states  is  but  partly  re- 
vealed in  these  statistics;  for  it  seems  reasonable  to  assume 
that  the  facilities  for  the  detection  and  prosecution  of 
crime  are  in  these  states,  like  other  social  institutions,  inferior 
as  compared  with  those  of  the  second  group  of  states,  so  that 
a  greater  amount  of  crime  remains  undetected,  and  unrepre- 
sented in  the  statistics  of  penal  institutions. 

However  this  may  be,  it  seems  certain  that  the  inade- 
quacy of  the  provisions  for  the  care  and  custody  of  cases  of 
mental  disorder  in  the  first  group  of  states,  regarded  from  its 
financial  aspect  alone,  does  not  carry  with  it  the  advantage 
of  economy,  for  what  may  be  saved  in  expenditures  for  the 
maintenance  of  the  insane  is  lost  in  increased  expenditures 
for  the  maintenance  of  convicted  criminals;  it  is,  indeed, 
not  unlikely  that  the  loss  is  far  greater  than  the  saving. 

To  give  the  student  a  more  direct  view  of  the  evidence 
showing  a  relationship  between  crime  and  mental  disorders 
we  could  do  no  better  than  to  quote  from  a  report  prepared 
by  Dr.  Anne  Moore,  in  which  several  pages  are  devoted  to 
a  consideration  of  the  crime  of  arson.^ 

"  Arson  is  a  common  crime  among  the  feeble-minded.  .  .  .  Many 
times  thousands  of  dollars'  worth  of  property  are  destroyed  and  many 
Uves  endangered  before  legal  proof  of  guilt  is  established.  On  con- 
viction these  persons  are  often  committed  to  penal  institutions,  only 
to  be  paroled  and  set  free  to  repeat  the  crime;  or  they  are  left  to 
serve  long  sentences  which  on  their  release  do  not  act  as  a  deterrent. 
The  Fire  Marshal  of  New  York  City  tells  me  that  a  sufficient  number 
of  cases  of  pyromania  have  come  to  his  attention  to  fill  a  special  insti- 
tution. Two  cases  have  come  to  my  knowledge  in  which  feeble- 
minded children  have  set  fire  to  the  clothing  of  other  children  with 
fatal  consequences. 

1  The  Feeble-minded  in  New  York.  A  report  prepared  for'the  Public 
Education  Association  of  New  York  by  Anne  Moore.     New  York,  1911. 


188  THE  PRACTICE  OF  PSYCHIATRY 

"  Between  the  dates  of  February  1,  1910,  and  July  12,  1910,  sixteen 
fires  occurred  in  the  district  bounded  by  Fifth  and  Lexington  avenues 
and  108th  and  119th  streets,  all  in  twenty-family,  five-story  tenements, 
and  all  of  similar  incendiary  origin.  These  fires  were  traced  to  a  feeble- 
minded youth  who  had  no  motive  for  the  deed  except  a  desire  for 
excitement.  When  he  visited  one  of  the  buildings  to  dehver  goods  his 
method  was  to  light  a  bundle  of  papers  which  he  had  previously  satu- 
rated with  kerosene  from  a  bottle  which  he  carried  with  him,  and 
leave  them  in  the  hallway,  in  a  corner  of  the  stairway,  or  in  the  cellar. 
He  was  caught  and  convicted  on  the  sixteenth  fire.  He  was  declared 
insane  and  is  now  confined  in  the  Central  Islip  State  Hospital. 

"  A  feeble-minded  man,  25  years  of  age,  started  45  fires  within 
three  months.  The  loss  was  estimated  at  a  quarter  of  a  million  dollars. 
He  usually  left  something  burning  in  the  airshaft  or  wood-bin.  At 
his  trial  he  was  declared  sane  and  was  sent  to  Elmira.  After  13  months 
he  was  released  on  parole  and  won  his  absolute  release. 

"  A  feeble-minded  boy,  living  in  Massachusetts,  set  fire  to  his 
grandfather's  house.  He  saved  himself  by  jumping  from  the  upper 
window  into  a  cherry  tree.  Afterwards,  he  set  fire  to  a  stable  in 
Gloucester,  Mass.,  and  was  sent  to  a  reform  school  for  two  and  a  half 
years.  After  his  release  he  set  on  fire,  one  by  one,  a  row  of  houses 
owned  by  different  clergymen,  called  '  holy  row.'  Later  he  burned  a 
house  belonging  to  the  father  of  the  district  attorney,  wascaught,  and 
convicted.  He  spent  four  years  in  Charlestown  Prison.  He  became 
religious  and  was  paroled  on  condition  that  he  go  to  another  state.  He 
came  to  New  York  and  for  a  time  was  under  Mrs.  Booth's  care. 
Afterwards  he  set  fire  to  a  barn  and  to  the  Bayside  Yacht  Club.  He 
was  caught  and  convicted.     He  is  now  in  Sing  Sing. 

"  What  this  means  in  money  may  be  gathered  from  following  the 
evidence  and  proceedings  in  any  case  of  arson,  a  common  crime  among 
mental  defectives. 

"  (1)  A  building  is  set  on  fire  with  attendant  danger  to  its  dwellers, 
and  loss  of  property  to  them  and  the  owner. 

"  (2)  The  fire  department  is  called  out.  Usually  six  companies, 
involving  one  battalion  chief,  72  men,  4  engines,  and  2  trucks,  the  police 
reserves,  usually  about  20  men,  and  an  insurance  fire  patrol  wagon 
with  an  officer  and  10  men,  respond  to  an  alarm. 

"  (3)  The  offender  is  arrested  by  a  police  ofiicer,  after  examination 
of  material  witnesses  by  a  fire  marshal. 

"  (4)  After  being  taken  to  the  station  house  the  incendiary  must 
go  before  the  magistrate;  and  if  brought  to  trial,  with  its  attendant 
delays,  much  time  of  many  different  salaried  officers  is  consumed  as 
well  as  that  of  the  material  witnesses. 

"  (5)  After  conviction  and  before  sentence  is  passed  a  probation 


MEDICO-LEGAL  QUESTIONS  189 

oflficer  may  be  asked  to  looR  into  the  history  of  the  case,  which  will  take 
at  least  a  week.  The  sentence  may  be  any  length  of  time,  up  to  40  years. 
"  All  this  expensive  machinery  need  not  have  been  used  in  the  case 
of  feeble-minded  incendiaries  if  they  had  been  cared  for  in  institutions 
at  the  proper  time." 


CHAPTER  XIV 

THE  PRACTICE  OF  PSYCHIATRY  (Concluded) 

EXTRAMURAL  PSYCHIATRY 

Twenty  or  twenty-five  years  ago  it  was  a  common  assump- 
tion that  psychiatric  cKnical  material  was  mainly  contained 
in  institutions  for  the  insane.  With  increasing  knowledge 
of  mental  disorders,  however,  it  eventually  became  evident 
that  vast  amounts  of  psychiatric  material,  often  unrecog- 
nized as  such,  existed  outside  of  institutions.  The  ques- 
tion thus  arose.  What  is  the  precise  amount  and  nature  of  the 
extramural  psychiatric  material? 

To  find  an  answer  to  this  question  surveys  of  mental  dis- 
orders have  been  undertaken  in  various  communities.  One 
such  survey,  recently  carried  out  in  Nassau  County,  N.  Y., 
under  the  auspices  of  The  National  Committee  for  Mental 
Hygiene,  embodies  method  and  viewpoint  gained  from  the 
experiences  of  similar  previous  undertakings.  The  follow- 
ing account  is  abstracted  from  the  report  of  that  survey  .^ 

To-day  the  question  of  the  prevalence  of  mental  disorders 
is  no  longer  an  academic  one.  One  no  longer  asks :  What  is 
the  percentage  of  "  insane,"  or  "  feeble-minded,"  or  "  men- 
tally defective "  persons  in  a  given  community?  But 
rather.  What  instances  of  social  maladjustment,  sufficiently 
marked  to  have  become  the  concern  of  public  authorities, 
are,  upon  investigation,  to  be  attributed  mainly  or  in  large 
measure  to  mental  disorders? 

All  efforts  hitherto  made  in  coping  with  the  problems  of 
vice,  crime,  pauperism,  and  disease  have  met  everywhere 

'  A.  J.  Rosanoff.  Survey  of  Mental  Disorders  in  Nassau  County, 
N.Y.    .1917. 

190 


EXTRAMURAL  PSYCHIATRY  191 

with  only  partial  success  at  best;  the  difficulty  has  been 
due  to  lack  of  any  clear  knowledge  of  underlying  causes.  In 
the  meantime  a  great  deal  of  evidence  has  been  accumulated 
in  the  course  of  psychiatric  progress  showing  that  these 
social  phenomena  are  in  large  part  causatively  related  to 
mental  disorders;  thus  the  main  object  of  the  survey  became 
to  study  the  nature  of  this  relationship. 

In  all  1592  mentally  abnormal  individuals  were  found, 
constituting  1.37%  of  the  total  population.^  These  were 
classified  as  follows: 

TABLE  10. 

Insane 394 

Epileptic 72 

Feeble-minded 634 

Constitutional  psychopathic  states 492 

The  same  cases  were  also  classified  sociologically  as 
follows : 

TABLE  IL 

Retardation  in  school,  truancy,  unruliness,  etc 189 

Sex  immorality 116 

Criminal  tendency ^ 81 

Dependency 280 

Inebriety,  including  drug  addictions 324 

Other  social  maladjustments 439 

No  maladjustment 163 

Of  these  cases  946,  or  0.82%  of  the  entire  population, 
were  judged  to  require  institutional  care,  whereas  only  365 
were  receiving  such  care. 

The  survey  has  shown  very  clearly  that  for  the  bulk  of 
cases  presenting  psychiatric  problems  the  benefit  of  psychia- 
tric study,  judgment,  and  treatment  is  not  available.  These 
cases  are  now  in  the  hands  of  the  police,  overseers  of  the 
poor,  justices  of  the  peace,  church  and  private  charitable 
organizations,  and  general  medical  practitioners. 

1  These  figures  do  not  include  an  estimate  of  cases  in  the  schools, 
which  would  raise  the  percentage  to  1.72. 


192  THE  PRACTICE  OF  PSYCHIATRY 

Similarly,  psychiatric  problems  in  cases  among  school 
children  are  left  without  attention  or,  seemingly,  even 
deliberately  avoided.  The  medical  examination  of  children 
in  schools  takes  into  account  height,  weight,  chest  expansion, 
eyes,  ears,  nose,  tonsils,  teeth,  etc.,  but  not  mental  condi- 
tion. Save  by  way  of  rare  exception,  where  a  special  class 
is  provided  for  persistently  retarded  children,  mental  abnor- 
malities or  pecuUarities  receive  no  attention  on  the  part  of 
the  educational  authorities.  This  is  prejudicial  not  only 
to  the  interests  of  the  abnormal  children,  but  of  the  others 
as  well.  It  is  clear  that  more  special  classes  are  required; 
small  school  districts  could  form  unions  for  the  joint  estab- 
Ushment  and  management  of  such  special  classes. 

An  extraordinary  opportunity  of  gaining  an  idea  of  the 
magnitude  and  nature  of  extramural  psychiatric  problems 
was  furnished  by  the  experience  in  the  organization  of  the 
National  Army  in  the  World  War.  The  following  statistics 
represent  the  numbers  of  various  neuro-psychiatric  cases 
per  100,000  recruits  discovered  and  rejected  by  local  draft 
boards  or  medical  officers  in  training  camps :  ^ 

TABLE  12. 

Mental  deficiency 1445 

Epilepsy • 516 

Constitutional  psychopathic  states 55 

Dementia  pra^cox 77 

Manic-depressive  psychoses 21 

Other  psychoses 137 

Psychoneuroses 153 

Alcoholic  psychoses 3 

General  paralysis 9 

Malingering ;  . .  1 

There  is  not  a  general  hospital,  health  board,  army  post, 
school,  charitable  institution,  police  station,  court  of  law, 
prison,  or  large  industrial  organization  in  the  country,  but 
which  has  daily  to  cope  with  psychiatric  problems. 

1  These  figures,  kindly  furnished  by  Dr.  C.  B.  Davenport,  are  from 
records  of  examination  of  2,753,922  recruits. 


PART   II 
SPECIAL  PSYCHIATRY 


CLASSIFICATION 

Sixteen"  years  ago,  when  the  first  French  edition  of  this 
Manual  was  pubhshed.  the  author  felt  it  incumbent  on 
himself  to  offer  a  sort  of  apolog;>^  for  following  KraepeHn's 
classification  of  mental  disorders.  Since  then  this  classi- 
fication has  supplanted  all  others  throughout  the  world,  so 
that  to-day  an  apology-  seems  no  longer  necessary.  TVe 
have,  however,  changed  the  arrangement  of  the  clinical 
groups,  placing  them  in  an  order  as  far  as  possible  according 
to  etiologj\ 

I.    CoXSTITrXIOXAL   DISOEDEPwS: 

Arrests  of  development. 
Epilepsy. 

Constitutional  psychopathic  states. 
Dementia  prsecox. 
Paranoia. 

Manic-depressive  psychoses. 
Involutional  melanchoha. 
Psychoneuroses. 
Huntington's  chorea. 
193 


194  CLASSIFICATION 

II.  Alcoholic  disorders: 

Pathological  drunkenness. 
Delirium  tremens. 
Acute  hallucinosis. 
Alcoholic  delusional  states. 
The  polyneuritic  psychosis. 
Alcoholic  dementia. 

III.  Drug  addictions: 

Opium,  morphine,  heroin,  cocaine. 

IV.  Syphilitic  disorders: 

Cerebral  syphilis. 
General  paralysis. 
Cerebral  arteriosclerosis. 

V.  Traumatic  disorders: 

Traumatic  delirium. 
Traumatic  constitution. 
Traumatic  epilepsy. 
Traumatic  dementia. 

VI.  Miscellaneous  groups: 

Infective,  exhaustive,  autotoxic,  thyrogenic,  organic, 
and  senile  psychoses. 

To  secure  uniformity  in  clinical  work  and  published 
reports  of  all  institutions  in  the  United  States  and  Canada 
the  American  Medico-Psychological  Association  adopted 
in  May,  1917,  a  classification  of  mental  diseases  with  the 
recommendation  that  all  members  introduce  it  in  their 
respective  hospitals.  This  classification  has  already  been 
made  the  official  one  in  many  states  and  it  is  important  for 
every  psychiatrist  to  familiarize  himself  with  it  thoroughly. 
We  have  therefore  reprinted  it  in  Appendix  VIII  together 
with  definitions  and  explanatory  notes  prepared  by  Dr. 
George  H.  Kirby,  a  member  of  the  committee  on  statistics. 


CHAPTER  I 

ARRESTS  OF  DEVELOPMENT:    IDIOCY,  IMBECILITY,  MO- 
RONISM,  BORDERLINE  CONDITIONS. 

Etiology. — Bad  heredity  is  by  far  the  most  common  and 
important  cause  of  arrests  of  development.  There  are, 
however,  other  factors  acting  during  intra-uterine  hfe  or  in 
infancy  or  early  childhood  which  may  cause  them;  two  of 
these  deserve  special  mention,  parental  alcoholism  and 
parental  syphihs. 

Alcoholism  in  all  its  forms  is  encountered  in  the  parents 
of  idiots  and  imbeciles:  chronic  alcoholism,  drunkenness  at 
the  moment  of  conception  or  during  pregnancy,  etc.  Statis- 
tics compiled  by  Bourneville  show  that  48%  of  idiots  and 
imbeciles  are  the  offspring  of  alcoholic  parents. 

These  figures  correspond  approximately  to  those  pub- 
lished by  most  other  authors.  Yet  the  question  of  the  effect 
of  parental  alcoholism  upon  the  offspring  cannot  be  said 
to  have  been  fully  answered.  The  fact  that  a  large  per- 
centage of  the  parents  of  defective  children  are  alcoholic 
lacks  significance  in  view  of  the  great  general  prevalence 
of  alcoholism  and  in  the  absence  of  accurate  data  concerning 
the  frequency  of  alcoholism  in  the  parents  of  normal  chil- 
dren. Further,  there  is  much  evidence  which  suggests  that 
alcoholism  is  often  but  a  symptom  of  neuropathic  consti- 
tution, so  that  abnormal  traits  in  the  offspring  of  alcoholic 
parents  may  possibly  be  attributable  to  inheritance  of  the 
neuropathic  taint  rather  than  to  the  injurious  effect  of  alcohol 
upon  the  germ  plasm.  Unfortunately  statistics  bearing 
upon  this  important  subject  have  not  always  been  very 
critically  examined. 

195 


196  ARRESTS  OF  DEVELOPMENT 

In  a  recent  memoir  from  the  Francis  Galton  Laboratory 
for  National  Eugenics,  University  of  London/  consisting  in 
a  statistical  research  of  this  subject,  we  find,  among  others, 
the  following  conclusions: 

"  There  is  a  higher  death  rate  among  the  offspring  of  alcoholic 
than  among  the  offspring  of  sober  parents. 

"  Owing  to  the  greater  fertility  of  alcoholic  parents,  the  net 
family  of  the  sober  is  hardly  larger  than  the  net  family  of  the  alcoholic. 

"  The  general  health  of  the  children  of  alcoholic  parents  ap- 
pears on  the  whole  slightly  better  than  that  of  the  children  of  sober 
parents.  There  are  fewer  delicate  children  and  in  a  most  marked  way 
cases  of  tuberculosis  and  epilepsy  are  less  frequent  than  among  the 
children  of  sober  parents. 

"  Parental  alcoholism  is  not  the  source  of  mental  defect  in 
offspring. 

"  The  relationship,  if  any,  between  parental  alcoholism  and 
filial  intelligence  is  so  slight,  that  even  its  sign  cannot  be  determined 
from  the  present  material." 

Inherited  syphilis  may  act  in  two  ways:  either  by  giving 
rise  to  a  congenital  anomaly  through  intra-uterine  disorders 
or  by  causing  the  appearance  of  meningeal  and  cerebral 
lesions  during  the  first  years  of  life  of  which  arrest  of  develop- 
ment is  the  consequence  .2 

First  Manifestations. — According  to  Sollier,  who  has  made 
an  extensive  study  of  these  anomalies,  the  principal  early 
manifestations  are: 

(a)  Difiiculty  in  taking  the  breast;  it  seems  each  time 
that  the  act  is  a  new  one  to  the  child ; 

(6)  Violent,  continued,  and  unprovoked  crying; 

(c)  Impossibility  of  fixing  the  child's  gaze; 

{d)  Lack  of  expression  in  the  physiognomy. 

Later  on,  at  the  age  when  intelligence  becomes  manifest 
in  normal  children,  the  signs  of  psychic  insufficiency  become 

1  Ethel  M.  Elderton  and  Karl  Pearson.  A  First  Study  of  the  In- 
fluence of  Parental  Alcoholism  on  the  Physique  and  Ability  of  the  Off- 
spring.    London,  1910. 

2  F.  Plant.  The  Wassermann  Sero-Diagnosis  of  Syphilis  in  its 
Application  to  Psychiatry.  (English  translation  by  Jelliffe  and  Casa- 
major.)     New  York,   1911. 


SYMPTOMS  197 

more  and  more  evident.  The  child  is  sad,  surly,  or,  on  the 
contrary,  extraordinarily  noisy  and  turbulent.  It  does  not 
speak  or  it  may  be  able  to  say  only  a  few  words  at  an  age 
when  other  children  already  dispose  of  quite  a  vocabulary. 
More  important  than  the  language  of  transmission  is  that  of 
reception.  The  chief  characteristic  of  the  congenital  im- 
becile is  the  restricted  number  of  words,  not  which  he  can 
pronounce,  but  which  he  can  understand. 

Physically  arrest  of  development  manifests  itself  most 
commonly  in  delayed  walking  and  delayed  acquisition  of 
sphincter  control.  The  so-called  anatomical  stigmata  of 
degeneration  are  often  seen,  the  most  significant  being  the 
cranial  deformities — microcephaly,  macrocephaly,  scapho- 
cephaly, extreme  brachy-  or  dolichocephaly. 

Symptoms. — As  with  the  growth  of  the  child  the  psychic 
functions  become  of  greater  importance,  their  insufficiency 
becomes  more  apparent  and  manifests  itself  in  the  im- 
possibility of  the  subject's  deriving  the  usual  benefit  from 
education.  There  is  delay  in  learning  to  talk  and  later 
unusual  difficulty  and  slowness  in  learning  to  read  and  write. 

School  age  is  eventually  outgrown  with  but  poor  educa- 
tional achievement,  if  any,  and  the  patient,  now  almost 
grown  up,  is  apt  to  begin  to  show  all  sorts  of  social  mal- 
adjustments: sex  immorality,  vagrancy,  criminal  tendency, 
dependency,  etc. 

The  mental  defect  varies  in  degree  in  different  cases,  and 
these  variations  constitute  the  basis  of  the  generally  adopted 
classification  into  four  principal  groups:  (1)  Idiocy.  (2) 
Imbecility.  (3)  Moronism  or  Feeble-Mindedness.  (4)  Bor- 
derline Conditions. 

These  groups  may  be  variously  defined.  In  cases  of 
adults  a  degree  of  general  intelligence  corresponding  to  that 
of  an  average  child  not  over  three  years  of  age,  as  determined 
by  mental  measurement,  characterizes  idiocy;  between 
three  and  seven  years,  imbecility;  between  seven  and  eleven 
years,  moronism;  and  between  eleven  and  twelve  years, 
borderline  conditions. 


198  ARRESTS  OF  DEVELOPMENT 

In  many  respects  it  is  preferable  to  use  as  a  measure  the 
"  intelligence  quotient "  (often  expressed  by  the  symbol 
IQ)  instead  of  the  mental  age.^  According  to  this  measure 
degrees  of  intelligence,  both  normal  and  abnormal,  have 
been  classified  as  follows :  ^ 

TABLE  13. 

Above  140 "  Near  "  genius  or  genius. 

120-140 Very  superior  intelligence. 

110-120 Superior  intelligence 

90-110 Normal,  or  average,  intelligence. 

80-  90 Dullness,  rarely  classifiable  as  feeble-minded- 

ness. 

70-  80 Borderline  deficiency,  sometimes  classifiable  as 

dullness,  often  as  feeble-mindedness. 

50-  70 Moronism. 

20-  50 Imbecility. 

Below     20 Idiocy. 

Very  practical  definitions,  from  a  sociological  standpoint, 
have  been  formulated  by  the  British  Royal  Commission  on 
the  Care  and  Control  of  the  Feeble-Minded : 

Idiots  are  persons  so  deeply  defective  in  mind  from  birth  or  from 
an  early  age  that  they  are  unable  to  guard  themselves  from  common 
physical  dangers,  such  as,  in  the  case  of  young  children,  would  prevent 
their  parents  from  leaving  them  alone. 

Imbeciles  are  persons  who  are  capable  of  guarding  themselves  from 
common  physical  dangers,  but  who  are  incapable  of  earning  their  own 
living  by  reason  of  mental  defects  existing  from  birth  or  from  an  early 
age. 

Feeble-minded  are  persons  who  may  be  capable  of  earning  a  living 
under  favorable  circumstances,  but  are  incapable  from  mental  defect 
existing  from  birth  or  from  an  early  age:  (a)  of  competing  on  equal 
terms  with  their  normal  fellows;  or  (b)  of  managing  themselves  and 
their  affairs  with  ordinary  prudence. 

While  it  is  possible  to  measure  quite  precisely  the  degree 
of  defect  in  cases  of  arrest  of  development,  it  is  hardly  pos- 

1  The  "  intelligence  quotient  "  is  the  ratio  of  mental  age  to  chrono- 
logical age.  It  is  used  particularly  in  connection  with  the  Stanford 
revision  of  the  Binet-Simon  intelligence  scale. 

2  Lewis  M.  Terman.  The  Measurement  of  Intelligence.  Boston, 
1916. 


SYMPTOMS  199 

sible  In  the  present  state  of  our  knowledge  to  define  exactly 
the  nature  of  it.  Perhaps  most  clearness  on  the  subject 
is  to  be  gained  from  Binet's  conception  of  intelligence, 
which  emphasizes  three  characteristics  of  the  thought 
process:  (1)  Its  tendency  to  take  and  maintain  a  definite 
direction;  (2)  the  capacity  to  make  adaptations  for  the 
purpose  of  attaining  a  desired  end;  and  (3)  the  power  of 
auto-criticism. 1 

As  an  illustration  may  be  taken  one  of  Binet's  series  of 
tests,  that  of  arranging  five  weights,  which  is  normally 
passed  at  the  age  of  nine  years : 

"  Success  depends,  in  the  first  place,  upon  the  correct  comprehen- 
sion of  the  task  and  the  setting  of  a  goal  to  be  attained;  secondly, 
upon  the  choice  of  a  suitable  method  for  realizing  the  goal;  and  finally, 
upon  the  ability  to  keep  the  end  clearly  in  consciousness  until  all  the 
steps  necessary  for  its  attainment  have  been  gone  through.  Elemen- 
tary as  are  the  processes  involved,  they  represent  the  prototype  of  all 
purposeful  behavior.  The  statesman,  the  lawyer,  the  teacher,  the 
physician,  the  carpenter,  all  in  their  own  way  and  with  their  own 
materials,  are  continually  engaged  in  setting  goals,  choosing  means, 
and  inhibiting  the  multitudinous  appeals  of  irrelevant  and  distracting 
ideas.  In  this  experiment  the  subject  may  fail  in  any  one  of  the  three 
requirements  of  the  test  or  in  all  of  them.  (1)  He  may  not  compre- 
hend the  instructions  and  so  be  unable  to  set  the  goal.  (2)  Though 
understanding  what  is  expected  of  him,  he  may  adopt  an  absurd  method 
of  carrying  out  the  task.  Or  (3)  he  may  lose  sight  of  the  end  and 
begin  to  play  with  the  blocks,  stacking  them  on  top  of  one  another, 
building  trains,  tossing  them  about,  etc. 

"  However,  an  examination  of  the  scale  will  show  that  the  choice 
of  tests  was  not  guided  entirely  by  any  single  formula  as  to  the  nature 
of  intelligence.  Binet's  approach  was  a  many-sided  one.  The  scale 
includes  tests  of  time  orientation,  of  three  or  four  kinds  of  memory, 
of  apperception,  of  language  comprehension,  of  knowledge  about  com- 
mon objects,  of  free  association,  of  number  mastery,  of  constructive 
imagination,  and  of  ability  to  compare  concepts,  to  see  contradictions, 
to  combine  fragments  into  a  unitary  whole,  to  comprehend  abstract 
terms,  and  to  meet  novel  situations."^ 

1  Binet  and  Simon.  L'intelligence  des  imbeciles.  L'Annee  Psy- 
chologique,  1919. — Lewis  M.  Terman.     Loc.  dt. 

2  Lewis  M.  Terman.     Loc.  cit. 


200  ARRESTS  OF  DEVELOPMENT 

Usually  both  normal  and  defective  subjects  furnish  more 
or  less  scattered  results  upon  application  of  intelligence  scales, 
i.e.,  they  pass  in  some  tests  at  higher  age  levels  and  fail 
in  others  at  lower  ones;  and  clinicians  have  often  reported 
cases  of  arrest  of  development  in  which  normal  or  even 
phenomenal  mental  capacity  was  observed  in  certain  limited 
directions — memory,  calculating  ability,  musical  ability, 
etc.  It  would  seem  from  all  this  that  the  nature  of  the  defect 
is  not  the  same  in  all  cases  of  arrest  of  development,  but  is 
merely  sufficiently  pronounced  and  sufficiently  general, 
in  respect  to  the  mental  faculties  involved,  to  seriously 
interfere  with  the  patient's  power  of  adjustment  to  ordinary 
conditions  of  life. 

The  defect  of  intelligence  in  cases  of  idiocy  and  imbecility 
is  generally  alone  sufficient  to  produce  serious  social  mal- 
adjustment. But  in  many  cases  of  moronism  and  border- 
line conditions  it  is  not  the  defect  of  intelligence,  but  some 
accompanying  temperamental  abnormality  that  is  the  main 
source  of  trouble.  Many  a  moron  of  a  mental  age  of,  say, 
nine  or  ten  years,  being  of  pleasant  disposition,  industrious, 
and  obedient,  leads  an  uneventful  existence  as  a  useful 
member  of  the  community,  while  many  another,  presenting 
no  greater  defect  of  intelligence,  but  being  indolent  or 
vicious,  becomes  a  problem  for  the  public  authorities  through 
dependency,  vagrancy,  prostitution,  incendiarism,  or  other 
antisocial  behavior. 

Complications. — The  most  common  physical  complica- 
tions are  epilepsy  and  more  or  less  marked  residuals  of 
infantile  cerebral  paralysis. 

In  some  cases  the  epilepsy,  in  the  course  of  years,  produces 
mental  deterioration,  and  the  imbecile  or  moron  becomes, 
in  addition,  an  epileptic  dement. 

Among  mental  complications  are  to  be  noted  acute  or 
subacute  episodes  which  appear  in  various  clinical  forms: 
maniacal  excitement,  depression,  sometimes  delusions  more 
or  less  imperfectly  systematized.  Often  the  mental  dis- 
orders appear  as  exaggerations  of  a  constitutional  anomaly, 


DIAGNOSIS  201 

essentially  a  function  of  the  patient's  make-up.  An  individ- 
ual habitually  touchy  and  suspicious  develops  persecutory 
delusions,  another  habitually  psychasthenic  suffers  an  attack 
of  depression,  etc.  Such  episodes  in  imbecility  are  incontest- 
able cUnical  realities,  and  nothing  is  more  justifiable  than, 
for  instance,  a  diagnosis  of  maniacal  excitement  in  an 
imbecile.  Unfortunately  it  is  very  difficult  to  assign  for 
such  episodes  a  place  in  psychiatric  nosography.  Do  they 
constitute  mental  disorders  peculiar  to  imbecility?  Are  they 
not,  on  the  contrary,  periodic  psychoses  to  which  the  im- 
becility merely  imparts  special  features:  mobility  of  the 
symptoms,  childish  character  of  the  delusional  conceptions? 
For  our  part  we  are  rather  inclined  toward  the  second 
hypothesis.  In  fact  a  full  series  of  transition  cases  leads 
from  classical  manic-depressive  psychoses  to  the  more  typical 
attacks  in  imbeciles.  Moreover,  such  attacks  in  imbeciles 
present  the  same  tendencies  toward  recovery  and  toward 
recurrency.  It  must  be  noted,  however,  that  the  influence 
of  external  causes,  psychic  as  well  as  physical,  in  bringing 
about  recurrencies,  appears  to  be  more  marked  in  imbeciles 
than  in  manic-depressive  persons  who  are  not  defective. 
It  is  also  to  be  noted  that  the  effect  of  suggestion  upon  the 
mental  symptoms  is  surely  more  pronounced  in  the  psychoses 
of  imbeciles  than  in  ordinary  types  of  recurrent  psychoses, 
so  that  psychic  treatment  is  here  found  to  be  more 
efficacious. 

Diagnosis. — In  the  diagnosis  of  arrests  of  development 
certain  precautions  and  certain  practical  requirements  should 
be  borne  in  mind. 

It  should  not  be  made  on  incomplete  evidence.  Illiteracy, 
or  gross  ignorance,  or  dependency,  or  low  social  status  ("  a 
common  laborer  all  his  life,"  "  of  the  domestic  servant 
class  ")  may  arouse  suspicion  of  mental  defectiveness  but 
would  not  suffice  to  establish  it,  being  often  largely  accounted 
for  by  environmental  conditions.  Similarly,  a  poor  showing 
in  psychological  tests  would  not  suffice  for  a  diagnosis,  but 
might  lead  to  mistaking  temporary  psychotic  disability  or 


202  ARRESTS  OF  DEVELOPMENT 

acquired  mental  deterioration  for  original  defect.  The  diag- 
nosis must  be  based  on  a  complete  psychiatric  investigation 
following  some  such  scheme  as  that  outlined  in  Chapters  V 
and  VI,  Part  I,  of  this  Manual,  and  including  family  history, 
personal  history,  history  of  present  disorder,  physical  exami- 
nation, mental  examination,  and  such  special  diagnostic 
procedures  as  may  be  indicated. 

The  diagnosis  being  established,  it  is  necessary  for 
practical  purposes  to  determine  the  degree  and  nature  of  the 
mental  defect.  In  the  management  of  a  given  case  it  is 
obvious  that  much  will  depend  on  whether  it  is  one  of 
totally  helpless  idiocy;  or  low,  medium,  or  high  grade 
imbecility;  or  low,  medium,  or  high  grade  moronism;  or 
borderline  intelligence  with  possibly  considerable  general 
educability  or  good  capacity  in  some  limited  directions. 
The  application  of  psychological  measurements  is  here  of 
great  assistance.  Similarly,  it  is  important  to  determine 
whether  the  patient's  difficulties  are  attributable  mainly  or 
largely  to  defect  of  intelligence  or  to  unruliness, .  eroticism, 
lack  of  emotional  control,  criminal  tendency,  or  other 
temperamental  anomaly.  The  social  history  or  several 
weeks  of  direct  observation  should  be  helpful  in  clearing  up 
these  questions. 

Prognosis. — In  cases  of  arrest  of  development  no  recovery 
is,  of  course,  to  be  looked  for;  but  much  can  be  accomplished 
in  a  practical  way,  as  the  student  may  judge  from  the  follow- 
ing discussion  of  treatment. 

Treatment. — The  general  measures  of  treatment  are: 
(a)  Training  and  education,  (h)  Segregation,  (c)  Board- 
ing out  and  employment  under  supervision. 

(a)  The  training  and  education  may  be  carried  out 
either  in  special  ungraded  classes  in  public  schools  or  in 
institutions  for  the  feeble-minded,  depending  on  tendencies 
or  degree  of  manageableness  of  the  given  case,  home  condi- 
tions, etc.  The  aim  is  mainly  to  train  the  patient  to  dress 
and  undress,  to  be  of  cleanly  habits,  to  behave  decorously, 
to  read  and  write  and  know  something  of  numbers,  to  tell 


TREATMENT  203 

time  by  the  clock,  to  keep  track  of  days  of  the  week  and 
month,  and  to  do  some  useful  work. 

"It  is  safe  to  say  that  over  50%  of  the  adults  of  the  higher  grade 
who  have  been  under  training  from  childhood  are  capable,  under 
intelligent  supervision,  of  doing  a  sufficient  amount  of  work  to  pay  for 
the  actual  cost  of  their  support,  whether  in  an  institution  or  at  home."  ^ 

(6)  Permanent  segregation  is  necessary  for  idiots,  im- 
beciles, defective  delinquents,  and  feeble-minded  women  of 
child-bearing  age. 

"  This  lower  class  of  idiots,  many  of  them  with  untidy,  disgusting, 
and  disagreeable  habits,  feeble  physically,  perhaps  deformed  and 
misshapen,  often  partially  paralyzed  or  subject  to  epilepsy,  cannot  be 
given  suitable  care  at  home.  There  is  no  greater  burden  possible  in  a 
home  or  in  a  neighborhood.  It  has  been  well  said  that  by  institutional 
care,  for  every  five  idiots  cared  for  we  restore  foin"  productive  persons 
to  the  community;  for,  whereas  at  home  the  care  of  each  of  these 
children  practically  requires  the  time  and  energies  of  one  person,  in  an 
institution  the  proportion  of  paid  employees  is  not  over  one  to  each 
five  inmates." 

"  Requiring  permanent  care  are  also  the  moral  imbecUes  and  the 
adults  of  both  sexes  who  have  graduated  from  the  school  department, 
or  are  past  school  age,  but  cannot  safely  be  trusted,  either  for  their 
own  good  or  the  good  of  the  community,  where  not  under  strict  and 
judicious  sm^'eillance. 

"  The  brighter  classes  of  the  feeble-minded,  with  their  weak  wiU 
power  and  deficient  judgment,  are  easily  influenced  for  evil  and  are 
prone  to  become  vagrants,  drunkards,  and  thieves."  "  As  a  matter  of 
mere  economy,  it  is  now  believed  that  it  is  better  and  cheaper  for  the 
community  to  assume  the  permanent  custody  of  such  persons  before 
they  have  carried  out  a  long  career  of  expensive  crime." 

"  The  tendency  to  lead  dissolute  lives  is  especially  noticeable  in  the 
females.  A  feeble-minded  girl  is  exposed  as  no  other  girl  in  the  world 
is  exposed.  She  has  not  sense  enough  to  protect  herself  from  the  perils 
to  which  women  are  subjected.  Often  sunny  in  disposition  and  physic- 
ally attractive,  they  either  marry  and  bring  forth  in  geometrical  ratio 
a  new  generation  of  defectives  and  dependents,  or  become  irresponsible 
sources  of  corruption  and  debauchery  in  the  communities  where  they 
Uve.  There  is  hardly  a  poorhouse  in  this  land  where  there  are  not 
two  or  more  feeble-minded  women  with  from  one  to  four  illegitimate 

^  Walter  E.  Fernald.  The  Growth  of  Provision  for  the  Feeble-Minded 
in  the  United  States.     Mental  Hygiene,  Jan.,  1917. 


204  ARRESTS  OF  DEVELOPMENT 

children  each.  There  is  every  reason  in  morality,  humanity,  and  public 
policy  that  these  feeble-minded  women  should  be  under  permanent 
and  watchful  guardianship,  especially  during  the  child-bearing  age. 
A  feeble-minded  girl  of  the  higher  grade  was  accepted  in  the  Massa- 
chusetts  School  for  the  Feeble-Minded  when  she  was  fifteen  years  of 
age.  At  the  last  moment  the  mother  refused  to  send  her  to  the  school, 
as  she  '  could  not  bear  the  disgrace  of  publicly  admitting  that  she  had 
a  feeble-minded  child.'  Ten  years  later  the  girl  was  committed  to  the 
institution  by  the  court,  after  she  had  given  birth  to  six  illegitimate  chil- 
dren, four  of  whom  were  still  living  and  aU  feeble-minded.  The  city 
where  she  lived  had  supported  her  at  the  almshouse  for  a  period  of 
several  months  at  each  confinement,  had  been  compelled  to  assume  the 
burden  of  the  life-long  support  of  her  progeny,  and  finally  decided  to 
place  her  in  permanent  custody."  ^ 

A  good  deal  of  segregation  can  be  accomplished  in  colonies 
maintained  by  the  parent  institutions  at  distances  of  from 
20  to  50  miles: 

"  During  the  past  decade  this  form  of  care  has  rapidly  grown,  so 
that  now  there  is  general  approval  of  the  formation  of  colonies  for  adult 
male  feeble-minded  persons  in  good  physical  condition.  Such  colonies, 
when  connected  with  '  parent '  institutions,  can  be  made  self-supporting 
and  seem  to  offer  a  most  hopeful  means  of  providing  for  a  greatly  in- 
creased number  of  cases  at  a  minimum  expense  to  the  state."  ^ 

(c)  The  success  of  institutional  training  and  discipline  is 
such  that  many  patients  can  eventually  return  to  their  homes 
or  be  boarded  out  and  employed  in  the  communities. 

"  The  next  step,  it  seems  to  me,  in  state  care  for  mental  defectives 
will  be  the  development  of  plans  for  the  supervised  care  of  suitable 
cases,  usually  those  who  have  had  a  period  of  institutional  observation 
and  training,  in  the  communities.  Many  such  patients  can  get  on 
in  their  homes,  while  others  may  be  '  boarded-out '  in  carefully  selected 
families  in  rural  communities,  subject  of  course  to  strict  supervision 
by  officers  of  the  parent  institution."  ^ 

1  Walter  E.  Fernald.     Loc.  cit. 

2  Walter  E.  Fernald.     Loc.  cit. 

3  Walter  E.  Fernald.  Loc.  cit. — See  also  C.  Bernstein.  Self- 
Sustaining  Feeble-Minded.     Ungraded,  Nov.,  1917. 


CHAPTER  II 
PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

From  a  psychiatric  standpoint  epilepsy  manifests  itself 
by  permanent  disorders  and  by  paroxysmal  accidents. 

Permanent  Psychic  Disorders. — These  impart  to  the 
epileptic  personality  a  peculiar  stamp  and  often  lead  one  to 
surmise  the  existence  of  the  disease  before  knowledge  of  any 
seizures  is  had.  We  shall  consider  separately  anomalies  of 
disposition  and  intellectual  disorders. 

(A)  Anomalies  of  Disposition. — These  are  often  very 
marked.     The  following  are  the  principal  ones: 

(1)  Irritabihty  and  variability  of  moods,  selfishness, 
duplicity. 

(2)  Habitual  apathy,  sudden  impulsive  reactions,  violent 
and  at  times  terrible  fits  of  anger. 

(3)  Lack  of  consistency  between  the  patient's  conduct 
and  his  ideas,  more  rarely  abnormal  stubbornness  and  te- 
nacity: "  Some  celebrated  men  who  are  supposed  to  have 
been  epileptics  are  more  noted  for  their  pertinacity  than 
for  the  greatness  of  their  conceptions."  ^ 

(4)  Morbid  religious  fanaticism,  not  constant,  but 
frequent,  usually  merely  ostentatious,  with  more  regard 
for  the  rites,  ceremonies,  and  customs,  and  without  influence 
upon  the  morahty  of  the  patient. 

(B)  Intellectual  Disorders. — Epileptics  are  sometimes, 
but  not  often,  as  claimed  by  some  authors,  men  of  great 
intelKgence.  Some  hold  prominent  places  in  history,  in 
hterature,  and  in  the  arts:  such  were  Ccesar,  Napoleon, 
Flaubert,  and  others.     Others,  though  in  a  more  modest 

^  Fere,    Les  epilepsies  et  les  epUeptiques,  p.  423. 
205 


206  PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

sphere,  are  honorable  occupants  of  offices  requiring  lucid 
intelligence  and  sane  judgment.  These  cases  are,  however, 
exceptional.  Intellectual  inferiority  as  a  rule  forms  a 
part  of  the  clinical  picture  of  epilepsy.  Often  it  is  congenital, 
for  most  epileptics  are  originally  feeble-minded;  in  other 
cases  it  is  acquired;  the  manifestations  of  epilepsy — convul- 
sions, fainting  spells,  psychic  attacks — exercise  a  harmful 
and  lasting  influence  upon  the  intelligence.  When  sufficiently 
marked,  the  mental  deterioration  becomes  epileptic  dementia. 

The  degree  of  dementia  depends  in  a  measure  upon 
the  number  and  severity  of  the  seizures.  "  It  cannot  be 
doubted  that  the  stupor  produced  by  the  major  attacks 
is  more  marked  than  that  resulting  from  minor  ones;  and 
it  is  certain,  as  is  admitted  by  Legrand  du  Saulle,  Voisin, 
Sommer,  etc.,  that  major  seizures  occurring  at  frequent 
intervals  much  more  rapidly  lead  to  dementia  than  do 
incomplete  seizures."  ^ 

The  two  essential  features  of  epileptic  dementia  are: 
(1)  its  irregularly  progressive  development,  with  aggrava- 
tions following  the  seizures;  (2)  its  being  to  a  certain  extent 
remittent,  the  apparent  deterioration  becoming  less  marked 
as  the  intervals  between  attacks  become  longer. 

Paroxysmal  Psychic  Disorders. — These  are  either  asso- 
ciated with,  or  replace,  the  epileptic  seizures.  We  shall 
review  briefly  their  principal  forms. 

(A)  Sensory  and  Psychic  Auras. — The  first  consist  in 
hallucinations  or  illusions;  the  second  "  usually  consist 
in  a  recollection  of  either  a  pleasant  or  an  unpleasant  charac- 
ter; perhaps  a  recollection  of  some  person  or  of  some  impor- 
tant event  in  the  patient's  life."  ^ 

(B)  Unconsciousness  Accompanying  the  Convulsive  Phe- 
nomena: though  most  frequently  complete,  it  is  sometimes 
but  partial,  so  that  there  may  be: 

(a)  Vertigo,  which  is  a  dazzling  sensation  rather  than 
true  vertigo,-^   and  which  is  sometimes,   but  not  always, 

1  Fere.     Loc.  cit.,  p.  227.  ^  Magnan.     hoc.  cit.,  p.  6. 

3  Fere.     Loc.  cit.,  p.  136. 


PAROXYSMAL  DISORDERS  207 

accompanied  by  falling  and  slight  convulsive  movements. 
Together  with  pallor  of  the  face,  these  phenomena  constitute 
a  rudimentary  epileptic  seizure. 

(6)  Absence,  essentially  characterized  by  a  momentary 
suspension  of  all  psychic  operations.  The  patient  sud- 
denly becomes  immobile,  his  gaze  fixed,  his  expression 
vacant;  the  attack  having  passed,  he  resumes  his  work 
or  conversation  at  the  point  where  he  left  off.  In  some 
cases  the  patient  continues  automatically  through  the 
attack  the  work  or  the  movement  in  which  he  happens  to  be 
engaged.  A  barber  mentioned  by  Besson  thus  continued 
during  his  absences  to  shave  his  clients,  performing  his  work 
just  as  skillfully  as  in  the  normal  state. 

Exceptionally  the  absence  is  prolonged  for  hours,  days 
or  even  weeks.  Fere  rightly  includes  with  these  absences 
those  peculiar  states  of  obscuration  which  are  known  as 
epileptic  automatism,  during  which  the  patient  may  execute 
complicated  acts,  such  as  taking  a  journey  somewhere, 
stopping  in  hotels,  etc.,  without  retaining  any  recollection 
of  them  after  the  attack.  Legrand  du  Saulle  has  reported 
a  curious  example  of  such  automatism:  an  individual  who 
was  at  Havre  when  his  attack  began,  found  himself  on  the 
way  to  Bombay  when  he  regained  consciousness,  totally 
ignorant  as  to  where  he  was  or  how  he  came  there. 

These  states  resemble  states  of  somnambulism,  with 
which  they  may,  in  fact,  coexist. 

(C)  Stupor  Following  the  Seizures:  This  is  a  constant 
phenomenon  which  constitutes  in  doubtful  cases  an  important 
element  of  diagnosis  (Samt).  It  varies  in  duration  from 
several  minutes  to  as  many  hours. 

(D)  Delirium:  This  is  the  gravest  manifestation  of 
epilepsy.  Sometimes  it  accompanies  a  convulsive  seizure; 
at  other  times  it  precedes  or  follows  it;  still  at  other  times 
it  takes  the  place  of  a  seizure. 

It  begins  with  an  accentuation  of  the  disorders  of  the 
emotions  and  of  the  character.  The  patient  becomes 
irritable,  anxious,  and  the  dehrium  establishes  itself  very 


208  PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

rapidly,  often  within  several  minutes,  and  never  taking 
more  than  a  few  hours  for  its  development. 

The  fundamental  features  in  the  classical  form  are: 

(a)  Profound  clouding  of  consciousness,  with  complete 
disorientation  of  time  and  place; 

(jS)  Anxiety  which  is  sometimes  terrible;  in  some  cases 
it  gives  rise  to  violent  agitation; 

(7)  Numerous  hallucinations,  combined  so  as  to  con- 
stitute complete  scenes,  associated  with  delusions  of  a 
painful  nature; 

(5)  Purely  automatic  and  extraordinarily  violent  reac- 
tions; the  extreme  limit  of  this  violence  is  known  as  epilep- 
tic furor.  In  this  condition  the  patient  often  commits 
crimes  of  revolting  brutality  bearing  the  stamp  of  absolute 
unconsciousness.  He  kills  indiscriminately  strangers  or 
his  own  children,  riddles  the  corpse  with  thrusts  of  his 
knife,  cuts  off  pieces  and  devours  them.  In  some  cases, 
which  are  rare  but  very  important  from  the  medico-legal 
point  of  view,  the  criminal  act  appears  to  be.  prompted 
by  the  usual  sentiments  of  the  patient.^  Suicide  is  some- 
times observed; 

(e)  Amnesia,  which  is  usually  absolute,  following  the 
attack.  All  classical  descriptions  show  that  the  patients 
are  as  a  rule  totally  ignorant  of  the  damage  or  of  the  crimes 
which  they  have  committed.  This  rule,  however,  has  some 
exceptions.  The  patient  may  have  a  recollection,  most 
frequently  very  vague,  of  the  acts  accomplished  by  him 
during  the  attack.  Three  classes  of  cases  may  present  them- 
selves: (1)  the  subject  may  retain  a  complete  or  partial 
recollection  of  the  delirious  period,  which  persists  as  an 
ordinary  impression;  (2)  the  recollection,  present  immedi- 
ately after  the  attack,  may  be  subsequently  effaced,  and  the 
patient  may  deny  facts  which  he  previously  admitted  to  be 
true;  (3)  inversely,  the  recollection,  absent  at  the  time 
when  the  patient  comes  to,  may  appear  later  on :  the  patient 
admits  a  fact  which  he  previously  denied.  The  recoUec- 
^  Fere.     Loc.  cit,  p.  144. 


EPILEPTIC  DELIRIUxM  209 

tions  of  epileptic  delirium  are  thus  similar  to  those  of  ordi- 
nary dreams.  We  may  forget  within  a  few  hours  a  dream 
which  we  remembered  very  clearly  at  the  time  of  awakening 
or,  more  rarely,  we  may,  on  the  contrary,  recollect  a  dream 
which  previously  seemed  to  have  left  no  impression  whatever 
upon  the  mind. 

Following  is  an  abstract  from  the  record  of  a  case  of 
epileptic  delirium: 

Louis  M.,  forty-two  years  old,  cab  driver.  Father  alcoholic. 
Patient  has  had  epilepsy  from  infancy.  Has  typical  epileptic  con- 
vulsions, though  not  frequent,  almost  exclusively  nocturnal,  occurring 
about  once  a  month.  Absences  of  long  duration :  one  day  the  patient 
found  himseK  driving  his  carriage  about  eight  miles  from  the  place 
where  he  wanted  to  go,  not  knowing  how  he  came  there. 

February  Y7^  1901,  toward  six  o'clock  in  the  evening,  following 
a  violent  dispute  with  a  neighbor,  the  patient  came  home  sad,  depressed, 
and  told  his  wife  that  he  would  throw  himself  into  the  river  rather 
than  hve  in  such  a  disagreeable  place.  He  went  to  bed  without  any 
supper  and  fell  asleep.  About  nine  o'clock  he  stood  up  in  his  bed, 
seeming  to  be  in  great  fear  and  emitting  inarticulate  cries,  then  ran  with 
nothing  on  but  his  shirt  into  the  next  room,  seized  a  hatchet,  and  came 
back  into  the  bedroom,  where  he  began  to  hack  away  at  everything 
within  his  reach.  His  wife,  terrified,  ran  out  and  called  for  help.  Some 
of  the  neighbors  came  but  no  one  dared  to  enter  the  bedroom.  In  the 
meantime  they  could  hear  the  strokes  of  the  hatchet  and  the  cracking 
of  the  furniture.  In  a  few  minutes  the  patient  went  at  the  door  of 
the  room,  kicking  it  with  his  feet  as  though  trying  to  break  it  down 
but  making  no  attempt  to  open  it.  Finally  three  men  climbed  into 
the  room  through  the  window  without  the  patient  hearing  them.  They 
approached  him  from  behind,  disarmed  and  overpowered  him,  and 
while  he  defended  himself  violently  and  tried  to  bite  them,  they  suc- 
ceeded by  the  greatest  efforts  in  getting  him  do-svTi  and  tying  him  to 
his  bed.  The  patient  struggled  violently  to  free  himself,  but  preserved 
complete  mutism  all  the  time  and  did  not  seem  to  recognize  anyone. 
His  respiration  was  panting,  skin  covered  with  perspiration,  pupils 
widely  dilated. 

Toward  five  o'clock  in  the  morning  consciousness  appeared  to  be 
returning.  The  patient  began  to  look  around  him,  noticed  with  aston- 
ishment the  straps  with  which  he  was  tied,  and  said  a  few  words: 
"  Take  this  off  from  me.  .  .  .  What  is  the  matter  with  aU  these 
people?  ..."  At  about  six  o'clock  he  fell  into  a  deep  sleep  and 
woke  up  at  noon,  tired  but  lucid.     He  had  some  recollection  of  the 


210  PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

beginning  of  the  attack.  He  said  he  had  had  an  impression  that 
someone  came  into  the  room  after  him  and  his  wife;  it  was  then  that 
he  uttered  the  cries  and  ran  to  get  the  hatchet.  After  that  he  could 
remember  nothing  up  to  the  time  that  he  found  himself  tied  in  his 
bed.  But  what  he  saw  even  then  he  remembered  but  vaguely:  he 
could  not  tell  who  were  the  people  whom  he  had  seen  around  his  bed 
and  said  he  believed  that  he  had  not  recognized  them  at  the  time. 
Finally  when  shown  the  damage  which  he  had  done  (the  furniture  in 
the  room  was  partly  destroyed),  he  was  stupefied  and  could  hardly 
believe  that  he  was  the  cause  of  all  the  destruction. 

An  attack  of  epileptic  delirium  lasts  from  a  few  minutes 
to  several  days.  It  may  be  reduced  to  a  single  automatic 
act.  Like  the  other  manifestations  of  epilepsy,  it  may  be 
produced  always  by  the  same  external  influence  and  assume 
the  same  form  each  time.  This  is  of  course  far  from  being 
always  the  case. 

The  termination  of  the  delirium  is  either  sudden,  following 
a  profound  sleep,  or  gradual,  leaving  for  several  hours  delu- 
sions and  hallucinations  which  persist  in  spite  of  the  return 
of  lucidity. 

The  above  is  a  description  of  the  most  common,  one 
may  say  classical,  form  of  epileptic  delirium.  Another 
form  is  occasionally  met  with  in  which  ideas  of  grandeur 
occur  in  place  of  the  painful  delusions;  these  ideas  often 
assume  a  mj'-stic  character  and  are  associated  with  a  state 
of  euphoria  which  may  reach  the  intensity  of  ecstasy. 

The  diagnosis  is  very  easy  when  these  phenomena  appear 
in  an  old  epileptic;  it  becomes  very  difficult,  however,  when 
the  epilepsy  is  "  masked,  or  atypical  in  its  course."'  ^ 

There  is  no  pathognomonic  sign  of  epileptic  delirium 
excepting,  perhaps,  the  stupor  which  follows  it  and  the 
importance  of  which  is  justly  insisted  upon  by  Samt  and 
MoeH.2  However,  this  stupor  may  be  so  slight  as  to  escape 
the  observation  of  those  witnessing  the  attack.  The  pre- 
vious history  of  the  patient  may  contain  nothing  to  aid  in 
the  diagnosis  because  delirium  sometimes  constitutes  the 

1  Magnan.     Loc.  cit.,  p.  2. 

2  Allg.  Zeitsch.  f.  Psychiat.,  1900,  Nos.  2  and  3. 


EPILEPTIC  DELIRIUM  211 

first  manifestation  of  epilepsy.     Only  upon  the  entire  symp- 
tom complex  together  with  the  previous  history  of  the  patient 
can  the  diagnosis  of  epileptic  delirium  or  of  any  other  epileptic 
manifestation  he  established. 
We  may  distinguish : 

Delirium  tremens  by  the  occupation  delirium,  intact 
autopsychic  orientation,  and  history  and  physical  signs  of 
chronic  alcoholism. 

Delirious  attacks  of  general  paralysis,  which  may  resemble 
epileptic  delirium,  by  the  clinical  history,  the  special  phys- 
ical signs  of  this  affection,  and  findings  in  the  cerebro-spinal 
fluid. 

Attacks  of  catatonic  excitement  by  the  relative  conserva- 
tion of  lucidity. 

Finally,  in  epilepsy  one  may  meet  with  attacks  of  so- 
called  epileptic  inania  which  at  times  simulate  closely  the 
nianic-depressive  psychoses.  However,  in  these  attacks 
flight  of  ideas  is  much  less  pronounced,  as  a  rule,  and  the 
morbid  ideas  are  much  more  firmly  fixed  and  much  more 
monotonous.^ 

Several  authors,  Krafft-Ebing  among  them,  have  de- 
scribed under  the  name  of  transitory  delirium,  or  transitory 
mania,  very  brief,  non-recurring  delirious  attacks  which 
they  consider  as  a  distinct  morbid  entity.  The  similarity 
between  these  attacks  and  those  of  epileptic  delirium  is  such 
that  most  psychiatrists  consider  them  as  being  of  epileptic 
origin,  at  least  in  the  great  majority  of  cases.  This  opinion 
is  held  notably  by  Schwartz,-  Regis,^  and  Vallon."^  Accord- 
ing to  these  authors  the  cases  of  transitory  delirium  which  are 
not  of  epileptic  origin  are  attributable  to  some  infectious 
disease,  alcoholism,  etc.  In  the  cHnic  only  a  close  study  of 
the  antecedents  of  a  given  case  enables  one  to  decide  to  which 
of  these  causes  the  attack  is  due. 

^  Heilbronner.     Ueber  epileptische  Manie  nebst  Bemerkungen  uber 
Ideenflucht.     Monatsch.  f.  Psychiat.  u.  Neurol.,  1902,  Nos.  3  and  4. 
2  Schwartz.     Mania  transitoria.     Allg.  Zeits.  f.  Psychiat.,  1891. 
^  Regis.     Manuel  de  maladies  mentales. 
*  Vallon.     Rapport  au  Congres  d' Angers,  1898. 


212  PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

Treatment. — Some  cases  of  epilepsy,  suffering  but  in- 
frequently from  seizures — perhaps  only  at  night — and  being 
free  from  psychic  disability,  can  and  do,  with  the  aid  of 
occasional  medical  advice,  lead  normal  lives. 

For  the  bulk  of  Cases,  however,  some  provision  of  control 
and  management  is  required.  The  treatment  of  these 
cases  will  be  discussed  briefly  under  the  following  captions: 
(1)  Prevention.  (2)  Education  and  training.  (3)  Social 
service.  (4)  Hygienic  measures.  (5)  Medication.  (6) 
Treatment  of  special  manifestations. 

(1)  Prevention. — This  is  eminently  a  problem  in  eugenics, 
the  factor  of  heredity  being  the  all  important  one  in  the 
etiology.^  The  segregation  of  epileptics  in  institutions  is  a 
practice  which  is  rapidly  growing  in  the  United  States,  so 
that  the  outlook  for  the  future  is  exceedingly  encouraging. 
The  National  Committee  for  Mental  Hygiene  reports  in  its 
second  annual  census  of  the  insane,  feeble-minded,  epileptics 
and  inebriates  in  institutions  in  this  country  that  on  January 
1,  1918,  there  were  11,944  epileptics  in  public  and  private 
institutions.  This  is  undoubtedly  an  understatement,  as 
"  No  attempt  was  made  to  secure  data  from  almshouses, 
penal  or  reformatory  institutions."  ^  Some  states  maintain 
special  institutions  for  epileptics,  which  would  seem  to  be  the 
best  plan.  Others  provide  for  their  care  and  treatment 
in  institutions  for  the  insane  or  feeble-minded. 

(2)  Education  and  Training. — For  some  cases  of  epilepsy 
this  presents  no  special  problems.  But  many  others,  being 
complicated  with  various  degrees  of  mental  defectiveness, 
require  special  provision  such  as  has  already  been  discussed 
in  the  chapter  on  Arrests  of  Development. 

(3)  Social  Service. — Epileptics  often  go  into  occupations 
which  are  dangerous  to  them  or  for  which  they  are  not  suited ; 

1  C.  B.  Davenport  and  D.  F.  Weeks.  A  First  Study  of  Inheritance 
in  Epilepsy.  Bulletin  No.  4,  Eugenics  Record  Office,  Cold  Spring 
Harbor,  N.  Y. 

2  H.  M.  Pollock  and  E.  M.  Furbush.  Annual  Census  of  the  Insane, 
Feeble-minded,  Epileptics,  and  Inebriates  in  Institutions  in  the  United 
States,  January  1,  1918.     Mental  Hygiene,  Jan.,  1919. 


TREATMENT  213 

more  often  they  lose  their  jobs  when,  owing  to  seizures 
while  at  work,  their  malady  is  discovered.  They  can  be 
greatly  benefited  through  social  service  by  being  placed  in 
suitable  employment  under  conditions  of  full  understanding 
with  employers  concerning  their  trouble,^ 

(4)  Hygienic  Measures. — These  consist  mainly  in  spe- 
cial diet,  abstinence  from  alcohol,  and  outdoor  life  with 
moderate  physical  and  mental  labor.  It  has  been  shown 
by  dietetic  experiments  ^  that  epileptics  have  a  special  intol- 
erance for  proteid  material  in  any  form,  and  that  when  their 
diet  contains  more  proteid  than  the  minimum  required  by 
the  organism  their  convulsions  are  more  frequent  and  more 
severe  and  their  mental  condition  is  worse  than  when  their 
diet  contains  no  such  excess.  The  principal  dietetic  indica- 
tion is,  therefore,  to  reduce  the  amount  of  proteid  to  the 
minimum  required  by  the  organism. 

(5)  Medication. — Of  all  the  drugs  used  in  the  treatment 
of  epilepsy  we  shall  mention  only  the  bromides  of  the  alkali 
metals  and  luminal. 

The  bromides  of  sodium  and  potassium  are  admin- 
istered either  separately  or  in  a  mixture  of  the  two  with 
bromide  of  ammonium,  which  mixture  is  sometimes  known 
as  the  "  tribromide."  The  doses  vary  according  to  age, 
frequency  of  attacks,  and  tolerance  of  the  patient.  The  maxi- 
mum that  may  be  administered  to  an  adult  with  benefit  seems 
to  be  from  8  to  10  grams  daily.  Usually  good  results  can  be 
obtained  from  moderate  doses — from  3  to  6  grams  daily. 

The  action  of  the  bromides  seems  to  be  more  pronounced 
when  the  patient  is  allowed  a  "  hypochlorization  "  diet; 
that  is  to  say,  a  diet  in  which  the  amount  of  sodium  chloride 
is  reduced  as  far  as  possible  (Richet  and  Toulouse).^ 

^  Margherita  Ryther  and  Mabel  Ordway.  Economic  Efficiency  of 
Epileptic  Patients.     Journ.  of  Nerv.  and  Mental  Disease,  May,  1918. 

2  Merson.  On  the  Diet  in  Epilepsy.  The  West  Riding  Lunatic 
Asylum  Medical  Report,  1875. — Rosanoff.  The  Diet  in  Epilepsy. 
Joum.  of  Nerv.  and  Mental  Disease,  Dec,  1905,  and  Dec,  1909. 

^  Capeletti  and  Ormea.  Le  regime  achlorure  dans  le  traitement 
hromure  de  I'epilepsie.     Rev.  de  Psychiat.,  Apr.,  1902. 


214  PSYCHIC  DISORDERS  ASSOCIATED  WITH  EPILEPSY 

The  prevailing  opinion  among  neurologists  is  against 
the  routine  administration  of  bromides  in  epilepsy.  The 
principal  indication  for  their  administration  would  seem 
to  be  frequent  and  severe  seizures  with  progressive  deteri- 
oration. The  course  of  medication  should  be  interrupted 
by  periods  of  a  month  or  two  of  suspension  of  medication. 

Luminal  in  doses  of  1|  grains  at  bedtime  has  been 
highly  recommended  of  late  by  Dercum  and  others.  "In 
a  number  of  instances  the  use  of  luminal  as  here  indicated 
has  resulted  in  the  abolition  of  the  convulsive  seizures  for 
periods  extending  not  only  over  many  months,  but  even 
over  several  years."  ^ 

(6)  Treatment  of  Special  Manifestations. — Excitement, 
such  as  occurs  in  epileptic  delirium,  has  to  be  treated  by 
methods  already  outlined  in  Chapter  VIII,  Part  I,  of  this 
Manual. 

Status  epilepticus,  i.e.,  continuous  repetition  of  seizures 
without  interval  of  consciousness  lasting  a  day  or  longer 
and  often  terminating  in  death,  must  be  promptly  combated 
with  an  enema  of  soapsuds  followed  by 

Chloral  hydrate 1  gram 

Potassium  bromide 2  grams 

Water 120  c.c. 

per  high  rectal  injection  given  slowly.  A  similar  injection 
should  be  given  again  at  the  end  of  an  hour  if  necessary. 
If  at  the  end  of  two  hours  after  the  second  injection  the 
seizures  still  continue,  ether  inhalations  may  be  given 
cautiously  so  as  to  avoid  producing  inhalation  pneumonia. 
Hypodermic  stimulation  with  strychnine  or  caffeine  may  be 
given  in  case  of  threatened  collapse  from  exhaustion.  As 
long  as  the  condition  lasts  rectal  feeding  is  to  be  preferred. 

1  F.  X.  Dercum.  On  the  Complete  Control  of  Epileptic  Seizures  by 
Luminal.     Therapeutic  Gazette,  Sept.  15,  1919. 


CHAPTER  III 
CONSTITUTIONAL  PSYCHOPATHIC  STATES 

There  is  a  large  group  of  persons  who,  though  not 
necessarily  suffering  from  epileptic,  psychotic,  or  psycho- 
neurotic s}Tiiptoms,  alcoholic  or  drug  addiction,  or  feeble- 
mindedness in  the  strict  sense  of  the  term,  are  nevertheless 
incapable  of  attaining  a  satisfactory  adjustment  to  the 
average  environment  of  civilized  society.  This  group  is 
very  heterogeneous,  yet  there  is  much  evidence,  in  family 
and  personal  histories  and  in  clinical  manifestations,  to  show 
that  the  various  conditions  comprised  in  it  are  in  some  way 
related  to  one  another  and  to  other  neuropathic  conditions. 

The  maladjustment  in  these  cases  seems  to  arise  on  a  basis 
of  inherent  anomalies  of  judgment,  temperament,  character, 
moral  sense,  or  sexual  make-up.  It  need  hardly  be  added 
that  both  the  underlying  defect  of  personality  and  the  social 
maladjustment  vary  in  degree  and  that,  moreover,  not  aU 
social  maladjustment  rests  upon  constitutional  abnormahty 
of  the  individual. 

Whatever  the  basic  anomaly  may  be  in  a  given  case,  it  is 
apt  to  become  manifest  in  childhood  or  early  youth,  but 
becomes  greatly  accentuated  with  emancipation  from 
parental  control  and  the  assumption  of  the  entire  burden 
of  social  adjustment  and  responsibility.  Thereupon,  sooner 
or  later,  the  individual  comes  to  the  attention  of  the  police, 
courts  of  law,  health  officers,  charitable  organizations, 
or  other  public  authorities  as  criminal,  prostitute,  vagrant, 
sanitary  menace,  or  dependent. 

In  some  cases,  of  a  milder  sort,  more  or  less  satisfactory 
adjustment  is  achieved  and  maintained  until  a  situation  arises 

215 


216         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

imposing  special  stress  or  new  exactions;  then  the  margin  of 
safety  is  wiped  out,  and  the  individual,  previously  regarded 
as  fairly  normal,  is  found  to  be  not  altogether  dependable. 
Thus  many,  who  in  ordinary  times  are  able  to  make  ends 
meet,  become  objects  of  charity  when  overtaken  by  illness  or 
confronted  with  unemployment  in  hard  times.  Thus  also  a 
previously  faithful  and  trusted  bank  clerk,  discouraged  by 
failure  to  gain  advancement  and  goaded  by  poverty,  yields  to 
temptation  and  becomes  involved  in  an  embezzlement. 
And  thus,  again,  the  World  War,  with  its  acid  test  of 
demand  for  great  personal  sacrifice,  suddenly  brought  to 
light  a  "  yellow  streak  "  in  some  men  previously  thought  to 
be  like  the  rest. 

The  prevalence  of  such  conditions  may  be  judged  from  the 
statistics  of  the  National  Army  in  the  World  War,  which  show 
that  of  all  recruits,  mainly  between  the  ages  "of  twenty-one 
and  thirty-one,  the  local  examining  boards  and  the  medical 
officers  in  training  camps  rejected  0.55  per  1000  for  con- 
stitutional psychopathic  states.  Some  more  subsequently 
came  to  light  in  men  who  had  been  accepted  for  service. 

Not  infrequently,  though,  as  already  stated,  by  no  means 
constantly  or  necessarily,  constitutional  psychopathic  states 
are  combined  or  complicated  with  mental  deficiency,  epilep- 
tic, psychotic,  or  psychoneurotic  episodes,  alcohol  or  drug 
addiction,  etc. 

The  following  varieties  of  constitutional  psychopathic 
states  have  been  distinguished  in  the  classification  adopted 
by  the  Surgeon  General  of  the  Army.  It  will  be  understood, 
of  course,  that  most  cases  represent  combinations  of  two  or 
more  of  the  various  traits  distinguished  in  the  classification. 
(1)  Inadequate  personality.  (2)  Paranoid  personality.  (3) 
Emotional  instability.  (4)  Criminalism.  (5)  Pathological 
lying.  (6)  Sexual  psychopathy.  (7)  Nomadism.  Follow- 
ing are  brief  descriptions  of  these  several  varieties. 

Inadequate  Personality. — These  cases,  either  from  lack 
of  initiative,  ambition,  perseverance,  or  judgment;  or 
through  shiftlessness  or  tactlessness;  or  a  planless,  improvi- 


INADEQUATE  PERSONALITY  217 

dent  existence,  and  often  in  spite  of  good  educational, 
social,  and  economic  opportunities,  make  an  egregious 
failure  of  everything  they  attempt.  The  following  case  is  a 
good  example: 

W.  S.,  male,  aged  44,  born  in  Nassau  County,  N.  Y.,  both  parents 
being  American  and  belonging  to  old  Long  Island  families.  "  Off  and 
on  I  worked  for  my  brother  H.,  in  the  hacking  business,  driving  a  hack; 
there  was  no  money  in  it  for  me;  just  worked  as  long  as  I  got  enough 
to  eat  and  a  place  to  sleep;  had  also  a  good  many  other  jobs;  worked 
for  about  a  year  for  a  clothing  firm  in  the  city;  also  was  in  the  plumbing 
business,  steamfitting  business,  glazing,  painting,  anything  that  came 
along;  then  went  in  the  brass  business;  then  went  into  the  calcium- 
light  business  for  a  theatre;  also  the  well-driving  business.  The 
calcium-light  business  might  have  turned  out  pretty  good,  but  a  lot 
of  kikes  got  into  it  and  beat  me  out  of  it.  I  was  married  in  the  fall 
of  1896,  at  the  age  of  24.  I  had  been  in  the  well-driving  business  all 
summer;  they  paid  $2.50  a  day;  but  the  job  lasted  only  until  a  week 
before  marriage,  and  after  that  I  didn't  have  anything  to  do  for  a 
year."  Q.  What  did  you  live  on?  A.  "  Sympathy,  and  what  little 
I  had."  Later  he  got  a  job  on  the  Long  Island  Railroad,  but  eventually 
gave  it  up.  Q.  Why  did  you  give  up  that  job?  A.  "  Too  much  work. 
I  asked  for  another  man  to  help  me;  they  wouldn't  give  me  one;  so 
I  took  a  vacation  and  never  went  back ;  I  had  no  intention  of  going  back ; 
life  is  too  short  and  sweet.  After  that  I  didn't  do  much  of  anything; 
was  baying  two  summers,  doing  any  old  thing  that  came  along  during 
the  winter." 

Local  charitable  organization  reports:  "  He  has  five  children  rang- 
ing from  twenty  years  to  fifteen  months  in  age ;  is  known  all  over  town 
for  his  laziness;  is  well  and  strong,  mentally  bright,  but,  on  slight 
provocation,  will  give  up  a  job  gotten  for  him;  often  refuses  work, 
demanding  three  or  four  dollars  a  day;  at  times  simply  says,  '  I  will 
not  work.'  Lets  his  wife  and  son  work  for  the  family;  wife  washes 
and  oldest  boy  works  on  ice  wagon;  has  received  aid  from  town,  church 
charities,  and  private  individuals,  mainly  for  his  children." 

Social  worker's  description  of  him  is  as  follows:  "  Goes  about  with 
thick  growth  of  hair  on  face;  will  not  shave  for  weeks  at  a  time;  will 
not  take  a  bath  or  change  his  clothes;  leaves  shirts  on  until  they 
shine  with  grease;  shoes  unlaced;  when  seen  by  me  had  one  shoe  partly 
tied  with  a  white  string,  the  other  unlaced  with  tongue  of  shoe  dragging 
along  the  ground." 

When  questioned  concerning  the  things  that  have  been  reported 
about  him,  said:  "  I  have  received  charity  ever  since  I  can  remember; 
suits  of  clothes,   and  so  on;  that's  only  a  case  of  good  fellowship.     As 


218         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

for  the  family  having  received  support  from  the  charities,  it  was  only 
through  their  own  will;  and  as  far  as  my  wife  and  son  working  to 
support  the  household,  that's  a  misstatement.  Of  course,  when  I 
wasn't  doing  anything  she  would  take  in  some  washes  to  assist;  but 
as  for  making  a  business  of  it,  that's  not  true.  I  admire  a  woman 
who  would  do  a  thing  like  that;  that  is,  more  for  the  benefit  of  the 
children  and  that's  all.  About  the  lazy  part,  I  can't  tell  you  anything 
about  it;  naturally,  I  suppose,  we  are  lazy,  more  or  less."  ^ 

Paranoid  Personality. — To  understand  this  condition, 
one  needs  but  to  make  a  study  of  paranoia,  from  which  it 
differs  but  in  degree.^  Conceit  and  suspicion,  which  are  the 
fundamental  traits  of  paranoia,  here,  too,  lie  at  the  root  of 
all  maladjustment;  only  here  they  do  not  leiad  so  far  as  to 
produce  a  delusional  system,  as  they  do  in  paranoia.  One 
sees,  however,  the  same  stubborn  adherence  to  a  fixed  idea, 
contempt  for  the  opinions  of  others,  bias  of  judgment  lead- 
ing to  distortion  of  practical  values,  argumentativeness,  and 
tendency  to  develop  persecutory  trends. 

Not  a  few  such  cases  were  seen  in  the  National  Army  in 
the  World  War  as  so-called  conscientious  objectors.  One 
draftee  was  opposed  to  killing  "  even  a  mosquito,"  lived  on 
vegetable  diet,  and  would  not  serve  even  in  a  non-combatant 
branch  of  the  army,  as  thus  he  would  be  giving  his  active 
support  to  the  ''  general  purpose  of  killing."  Another,  a 
third-rate  sculptor  with  a  predilection  for  a  bizarre,  symbolic 
art,  let  his  hair  grow  long,  wore  only  bedroom  slippers  every- 
where and  in  all  kinds  of  weather,  and  would  not  put  on  a 
soldier's  uniform  and  obey  the  law  of  conscription  for  the 
reason  that  "  being  an  artist,  and  art  being  constructive, 
I  could  take  no  part  in  war,  which  is  destructive."  Some 
negroes  were  seen,  who,  though  formerly  "  wicked,"  had 
recently  become  "  converted  "  and,  as  "  Christians,"  could 
not  go  to  fight  their  fellow  men. 

A  considerable  group  was  made  up  of  "  International 

1  A.  J.  Rosanoff.  Survey  of  Mental  Disorders  in  Nassau  County, 
N.  Y.  Report  published  by  The  National  Committee  for  Mental 
Hygiene,   New  York,  1917. 

2  Sec  Chapter  V,  Part  II,  this  Manual. 


EMOTIONAL  INSTABILITY  210 

Bible  Students  "  or  ''  Russellites."  One  of  these  wrote  a 
fifty-page  explanation,  concluding  it  with  the  following 
remarks : 

"  No  doubt  these  words  will  seem  kind  of  foolish  to  you,  because  the 
Bible  says  that  men  with  earthey  idears  and  ambitions  cannot  under- 
stand speritual  things.  So  I  hope  that  you  can  see  that  I  am  not  trying 
to  save  my  own  skin,  by  evadeing  the  military  service,  as  I  have  ex- 
plained, that  I  have  seen  through  the  Bible,  where  we  people  are  all 
born  in  sin,  and  cannot  do  anything  perfect,  and  that  this  war  is  only 
to  bring  around  the  conditions  that  will  make  the  people  look  to  God 
for  everything  later.  And  I  have  been  trying  to  live  up  to  God's  laws, 
and  am  running  for  the  high  prize,  and  hope  to  make  it,  probably  in 
the  spring  of  1918.  As  this  year  (1918)  Text  of  the  International  Bible 
Students'  Association  is  1  Peter  4:7  and  8.  The  end  of  all  things  is 
at  hand:  be  ye  therefore  sober  and  watch  unto  prayer,  and  above  all 
things  have  fervent  love  among  yourselves.  I  believe  I  have  written 
enough  to  explain  my  proof— against  participating  in  war,  however  if 
not  enough  why  I  have  plenty  more." 

Emotional  Instability. — Often  the  dominant  note  in  the 
character  of  the  psychopath  is  extreme  mobility  of  the  emo- 
tions. The  subject  passes  alternately  from  exuberant  joy 
to  boundless  desolation,  from  feverish  activity  to  profound 
discouragement,  from  affection  to  hatred,  from  the  most 
complete  egoism  to  the  most  exaggerated  generosity  and  de- 
votion. 

A  special  type  of  emotionally  unstable  psychopaths  is 
found  among'impulsive  criminals.  They  fly  readily  into  un- 
controllable rage  and  commit  violent  assaults.  Punishment 
seems  to  have  no  deterrent  effect.  These  subjects  are  given 
not  only  to  repetitions  of  crimes  of  violence  upon  release  from 
imprisonment,  but,  even  while  serving  sentence  where 
there  can  be  no  chance  of  escaping  consequences,  they  yield 
to  their  impulses,  assault  other  prisoners  or  keepers,  and  lose 
their  chance  of  release  for  which  they  long  so  impatiently. 

Criminalism. — By  reason  of  its  complexity  the  moral 
sense  is  one  of  the  most  delicate  and  most  vulnerable  func- 
tions of  the  mind.  Thus  we  find  it  altered  in  most  of  the 
psychoses,  especially  those  accompanied  by  mental  deteri- 
oration. 


220         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

There  is,  however,  a  condition,  which  has  been  variously 
termed  moral  insanity,  moral  imbecility,  and  inborn  criminal- 
ism, and  in  which  defect  of  moral  sense  exists  more  or  less 
independently  of  feeble-mindedness,  psychotic  disease,  or 
mental  deterioration. 

This  condition  finds  early  expression  in  perversities  of 
character  and  conduct.  The  child  is  naughty,  cruel,  deceit- 
ful, irritable,  violent;  or  he  is,  on  the  contrary,  taciturn 
and  dissembling. 

Education  totally  fails  to  modify  such  natures.  The 
moral  sense  is  not  built  upon  notions  acquired  through  intel- 
lectual culture.  It  is  the  result  of  a  special  sensibility,  of  a 
function  which  the  psychic  organ  lacks  in  these  cases. 
"  When  this  apparatus  is  absent,  the  most  favorable  sur- 
roundings fail  to  exercise  their  influence."  ^ 

As  the  child  becomes  a  man,  as  he  comes  into  more  direct 
contact  with  society,  his  infirmity  becomes  more  manifest. 
The  dominant  feature  is  seen  to  be  profound  egoism  com- 
bined with  complete  indifference  with  regard  to  right  and 
wrong. 

The  exclusive  aim  of  such  an  individual  is  his  pleasure 
or  his  own  interest  (and  very  often  he  has  but  poor  judg- 
ment as  regards  even  his  own  interest),  and  to  reach  this 
aim  he  does  not  hesitate  to  use  any  means  or  any  expedient. 
He  has  neither  sentiment  of  honor  nor  respect'  for  the  truth. 
His  unique  preoccupation  is  to  escape  conviction  and 
punishment. 

Cruel  and  malicious  toward  his  inferiors  and  toward 
the  weak  in  general,  he  is  cowardly  toward  anybody  who  is 
above  him.  In  the  asylum  or  prison  he  quite  readily 
submits  to  the  rules  and  to  the  discipline  and  does  not  aban- 
don himself  to  his  morbid  propensities  until  he  regains 
his  liberty. 

Undoubtedly  there  are  cases  of  moral  defectiveness  with 
a  sane  judgment  and  a  strong  will.     These,  freed  from  the 

1  E.  Bleuler.  Der  geborene  Verbrecher.  1896. — B.  Glueck.  A  Study 
of  608  Admissions  to  Sing  Sing  Prison.     Mental  Hygiene,  Jan.,  1918. 


CRIMINALISM  221 

scruples  which  might  interfere  with  their  liberty  of  action, 
occasionally  have  a  brilliant  career. 

Almost  always,  however,  other  psychic  anomalies  are 
present  in  addition  to  the  disorders  of  the  moral  sphere. 
The  most  frequent  are : 

(a)  Weakness  of  judgment:  the  subject  realizes  but 
imperfectly  the  possible  consequences  of  his  acts,  and  in 
spite  of  all  his  precautions  he  ultimately  comes  into  conflict 
with  the  law.  The  thoughtlessness  of  criminals  is  well 
known. 

(6)  Absence  of  perseverance:  this  prevents  the  utiliza- 
tion of  any  aptitudes  which  the  patient  may  possess  and 
which  are  in  some  instances  very  considerable. 

(c)  Impulsiveness:  moral  defectives  readily  yield  to  the 
first  impulse,  so  that  it  is  difficult  in  practice  to  distinguish 
them  from  the  impulsive  criminals.  The  best  criterion  is 
the  existence  of  subsequent  remorse  in  the  latter.  Unfor- 
tunately, it  is  impossible  to  determine  its  true  degree  of  sin- 
cerity. It  is  well  known  with  what  consummate  art  hardened 
criminals  simulate  the  most  touching  remorse. 

(d)  Diverse  other  psychic  anomalies:  obsessions,  morbid 
emotionalism,  etc. 

Pathological  Lying. — This  consists  in  "  falsification  en- 
tirely disproportionate  to  any  discernible  end  in  view, 
engaged  in  by  a  person  who,  at  the  time  of  observation, 
cannot  definitely  be  declared  insane,  feeble-minded,  or 
epileptic.  Such  lying  rarely,  if  ever,  centers  about  a  single 
event;  although  exhibited  in  very  occasional  cases  for  a 
short  time,  it  manifests  itself  most  frequently  by  far  over  a 
period  of  years,  or  even  a  lifetime.  It  represents  a  trait 
rather  than  an  episode.  Extensive,  very  complicated  fab- 
rications may  be  evolved.  This  has  led  to  the  synonyms: 
mythomania;  pseudologia  phantastica."  ^ 

The  following  case  is  reported  by  Healy: 

Janet  B.,  nineteen  years  old,  made  her  way  alone  to  New  York, 

^  W.  and  M.  T.  Healy.  Pathological  Lying,  Accusation,  and  Swind- 
ling.    Boston,  1917 


222         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

and  there  readily  obtained  emploj^ment.  After  a  couple  of  weeks  she 
approached  a  department  manager  of  the  concern  for  which  she  worked 
and  related  a  long  story,  which  at  once  aroused  his  sympathy.  She 
told  him  that  her  father  and  mother  had  died  in  the  last  year  and  that 
she  was  entirely  dependent  upon  herself.  When  she  was  about  four 
years  of  age  she  had  been  in  a  terrible  accident  and  a  certain  man  had 
saved  her  hfe.  Naturally  her  father  had  always  thought  very  highly 
of  this  person  and  had  pensioned  him.  Formerly  he  Uved  up  in  the 
country  with  his  family,  but  at  present  was  old,  penniless,  and  alone 
in  the  city.  Now  that  her  parents  were  dead  she  was  in  a  quandary 
about  keeping  up  her  father's  obhgation  to  the  old  man.  Out  of  her 
$8  a  week  it  was  hard  to  make  both  ends  meet.  She  had  to  pay  her  own 
board  and  for  this  man  also.  She  found  that  he  needed  to  be  taken 
care  of  in  every  way;  she  had  to  wash  his  face  and  dress  him,  he  was 
so  helpless.  She  made  no  demand  for  any  increase  of  salary  and  the 
story  was  told  evidently  without  any  specific  intent.  The  services 
of  a  social  worker  were  enlisted  by  the  firm  and  the  girl  reiterated  the 
same  story  to  her,  even  though  it  was  clearly  intended  that  the  case 
should  be  investigated.  Janet's  boarding-house  was  visited  and 
there  she  was  foimd  to  be  hving  with  distant  relatives  whom  she  had 
searched  out  upon  her  arrival  in  the  city.  They  knew  she  had  run 
away  from  home,  and  indeed  by  this  time  the  mother  herself  was 
already  in  New  York,  having  been  sent  for  by  them. 

She  then  acknowledged  that  this  story  of  a  man  who  had  saved  her 
life  was  purely  an  invention.  Now  she  stated  that  in  the  western 
town  where  she  hved  she  had  been  engaged  to  a  young  man  who  was 
discovered  to  be  a  defaulter  and  who  had  recently  died.  When  this 
fellow  was  in  trouble,  his  mother,  while  calling  on  Janet's  family, 
used  to  make  signals  to  her  and  leave  notes  under  the  table  cover, 
asking  for  funds  with  which  to  help  him  out.  This  was  a  great  strain 
upon  Janet  and  even  more  so  was  his  death.  She  could  stand  it  no 
longer  and  fled  the  city.  Her  lover's  stealing  was  a  secret  which  she 
had  kept  from  her  owti  farmly. 

Before  we  had  become  acquainted  with  the  true  facts  about  the 
family  this  girl  gave  us  most  extensive  accoimts  of  various  phases  of 
her  home  life  which  included  the  most  imlikely  and  contradictory 
details.  For  instance,  they  had  a  large  house  with  beautiful  grounds, 
yet  before  she  left  home  she  bought  a  sewing  machine  for  her  mother, 
which  she  is  paying  for  on  weekly  installments.  Her  S8  a  week  is 
very  httle  for  her  to  live  on  because  she  is  paying  this  indebtedness. 
Janet  wishes  now  to  take  out  a  twenty-year  endowment  policy  in  favor 
of  her  mother.  She  expects  to  take  up  French  and  Spanish  in  the  even- 
ings because  they  would  be  very  helpful  to  her  commercially.  She 
has  no  desire  for  social  affairs.  She  is  only  desirous  of  improving 
her  education.     She  relates  her  success  as  a  Sunday  School  teacher. 


SEXUAL  PSYCHOPATHY  223 

The  most  notable  finding  was  Janet's  facial  expression  when  con- 
fronted by  some  of  her  incongruities  of  behavior.  Then  she  assumed 
a  most  peculiar,  open-eyed,  wondering,  dumb  expression.  When 
flatly  told  a  certain  part  of  her  story  was  falsehood,  she  looked  one 
straight  in  the  eyes  and  said  in  a  wonderfully  demure  and  semi-sorrow- 
ful manner,  "  I  am  sorry  you  think  so."  Her  expression  was  sincere 
enough  to  make  even  experienced  observers  half  think  they  must 
themselves  be  wrong. 

The  story  of  this  girl's  falsifications  and  fabrications  as  obtained 
from  her  people  is  exceedingly  long.  Somewhere  about  twelve  years 
of  age,  her  parents  cannot  be  certain  just  when,  they  noticed  she 
began  the  exaggeration  and  lying  which  has  continued  more  or  less 
ever  since. 

The  type  of  Janet's  lying  has  been  not  only  in  the  form  of  falsi- 
fications about  matters  which  directly  concerned  herself,  but  also  in- 
volved extensive  manufacture  of  long  stories,  phantasies.  Meeting 
people  she  might  give  them  extensive  accounts  of  the  wealth  and 
importance  of  her  own  family.  She  once  spread  the  report  that  her 
sister  was  married  and  living  in  a  fine  home  close  by,  giving  many 
elaborate  details  of  the  new  household.  Such  stories  naturally  caused 
much  family  embarrassment.  Then  she  worked  up  an  imaginary 
entertainment  and  gave  invitations  to  her  brothers  and  sister  at  the 
request  of  a  pretended  hostess.  Just  before  the  event  she,  simulating 
the  hostess,  telephoned  that  an  accident  had  taken  place  and  the 
party  would  not  be  given.  An  extremely  delicate  situation  arose  be- 
cause she  alleged  a  certain  young  man  wanted  to  marry  her.  The 
truth  of  her  assertion  in  this  matter  never  was  investigated.  The 
parents  felt  it  quite  impossible  to  go  to  the  young  man  about  the  facts 
on  account  of  the  danger  of  exposing  their  daughter.  They  were  long 
embarrassed  by  the  extent  to  which  she  kept  this  affair  going,  but 
it  finally  was  dropped  without  any  social  scandal  occurring.  In  this 
and  other  affairs  the  family  situation  was  at  times  unbearable  because 
of  the  possibility  that  there  might  be  some  truth  underlying  the  girls' 
statement.  As  the  years  went  on  Janet,  of  course,  suffered  from  her 
loss  of  reputation,  but  still  continued  her  practices  of  lying. 

Sexual  Psychopathy.^ — Among  the  anomahes  of  sexual 
life  it  is  usual  to  distinguish: 

(A)  Anomalies  of  degree:  eroticism;  frigidity. 

(B)  Anomahes  of  nature:  sexual  perversion;  sexual 
inversion. 

(A)  Anomalies  of  Degree. — Eroticism  results  in  venereal 
excesses  and  often  in  indecent  acts  and  attempts  of  rape. 
1  R.  V.  Krafft-Ebing.     Psychopathia  Sexualis. 


224         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

Sexual  frigidity  consists  in  an  indifference  and  even 
an  aversion  of  the  subject  to  sexual  connection;  at  least 
to  normal  sexual  connection,  for  frigidity  may  be  associated 
with  sexual  perversion  or  inversion,  A  curious  and  appar- 
ently paradoxical  fact  is  its  frequency  among  prostitutes. 

(B)  Anomalies  of  Nature. — (a)  Sexual  'perversion  con- 
sists in  the  abnormal  character  of  the  conditions  necessary 
to  excite  sexual  desire  and  sometimes  its  gratification.  Its 
most  common  forms  are  masturbation,  fetichism,  exhibition- 
ism, sadism,  masochism,  bestiality  and  necrophilia. 

Masturbation  is  very  frequent  in  psychopaths.  Often 
appearing  very  early  it  is  to  be  regarded  as  a  sign  and  not  as 
a  cause  of  the  abnormality,  though  in  all  probability  it 
accentuates  already  existing  defects. 

Fetichism  occurs  almost  exclusively  in  men;  it  is  an 
anomaly  in  which  sexual  excitement  and  sometimes  even 
gratification,  accompanied  by  ejaculation,  are  produced  by 
the  sight  or  contact  of  certain  objects,  or  of  certain  parts  of 
the  female  body  other  than  the  genital  organs. 

Fetiches  may  be  (a)  various  objects:  articles  of  clothing 
(gowns,  petticoats,  handkerchiefs),  toilet  articles,  laces, 
expensive  fabrics,  in  a  word,  all  objects  used  by  women; 
(/3)  parts  of  the  body:  the  breasts,  the  hands,  the  feet,  the 
hair.  Several  fetiches  may  be  associated  in  the  mind  of 
the  same  patient. 

Moll  has  justly  remarked  that  the  mere  fact  that  an 
individual  has  a  predilection  for  some  portion  of  the  female 
body  does  not  in  itself  constitute  fetichism.  "  One  may  like 
by  preference  a  pretty  mouth,  light  or  dark  hair,  or  large 
eyes,  without  having  any  genital  perversion."  Similarly  a 
letter  or  an  object  belonging  to  a  woman  may  produce  an 
agreeable  impression  by  the  recollections  which  it  arouses. 
An  anomaly  is  present  only  when  the  presence  or  mental 
representation  of  such  objects  is  in  itself  sufficient  and  pro- 
vokes sexual  excitement  without  giving  rise  to  recollec- 
tion of  any  particular  woman. 

Fetichism  often  appears  at  the  time  when  normally  the 


SEXUAL  PSYCHOPATHY  225 

sexual  instinct  becomes  manifest.  The  choice  of  the  fetich 
depends  upon  the  impression  which  is  accidentally  associ- 
ated with  the  first  genital  excitement.  AYhile  in  the  normal 
indi\ddual  this  accidental  association  leaves  no  trace,  in  the 
fetichist  the  impression  and  the  excitation  form  an  indis- 
soluble combination,  so  that  the  first  invariably  brings 
about  the  second. 

The  desire  to  possess  the  fetich  is  sometimes  so  intense 
as  to  lead  the  patient  to  thefts  or  to  various  strange  acts. 
One  patient  of  Vallon's  was  arrested  while  cutting  bits  of 
cloth  from  the  dresses  of  women  who  were  with  him  at  the 
time  in  a  newspaper  office.  Most  of  the  so-called  hair 
despoilers  are  hau-  fetichists. 

Exhibitionism  may  be  met  with  in  dements  and  epileptics, 
and  often  takes  the  form  of  an  mipulsive  obsession. 

Sadis7n  consists  in  a  sense  of  voluptuousness  derived  from 
suffering  which  the  patient  witnesses  or  inflicts  upon  his 
victim.  This  sense  is  almost  always  associated  with  a  state 
of  genital  excitation.  As  is  the  case  with  most  sexual 
anomalies,  it  is  more  frequent  in  men. 

History  contains  terrible  examples  of  sadism.  Such 
is  that  of  Marshal  Gilles  de  Rays,  who,  during  a  period  of 
eight  years,  assassinated  over  eight  hundred  children,^ 
subjecting  them  previously  to  defilement  and  tortmre. 

Sadism  is  exercised  chiefly  upon  women  and  children; 
more  rarely  upon  animals. 

]\Iany  sadists  content  themselves  with  simulation  of 
suffering  or  with  fictitious  himiihation  inflicted  upon  their 
pseudo-^dctim.     The  sadism  is  then  symbolic  (Krafft-Ebing). 

Masochis.n,  unlike  sadism,  is  more  frequent  in  women. 
It  consists  in  an  abnormal  pleasure  which  the  subject  derives 
from  his  or  her  own  suffering  or  humihation.  To  this  cate- 
gory belong  the  individuals  who  request  women  to  strike 
and  insult  them  and  in  vrhom  sexual  excitation  cannot  be 
produced  otherwise. 

Bestiality  consists  in  an  impulse  to  copulate  with  animals. 
1  Quoted  by  Rrafft-Ebing  from  Jacob,  the  historian. 


226         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

Like  all  genital  impulses  it  often  assumes  the  shape  of  an 
imperative  idea  which  the  subject  can  in  some  cases  resist 
by  an  effort  of  the  will  or  bj^  various  curious  subterfuges. 
Magnan  cites  a  case  of  a  young  girl  who,  seized  with  the 
idea  of  having  connection  with  a  dog,  escaped  the  morbid 
impulse  by  turning  her  attention  to  another  animal. 

Necrophilia  is  the  rarest  of  all  forms  of  sexual  per- 
version. It  consists  in  a  particular  pleasure  which  the 
subject  experiences  from  the  sight  or  contact  of  a  cadaver. 
Often,  but  not  always,  this  is  accompanied  by  an  impulse 
to  defile  the  corpse. 

(6)  Sexual  inversion  consists  in  a  contrast  existing 
between  the  physical  sex  and  the  psychic  sex:  the  subject 
presents  the  sexual  tendencies  of  the  opposite  sex. 

Much  more  frequent  in  men  than  in  women,  sexual 
inversion  often,  but  not  always,  leads  to  pederasty.  Sexual 
inversion  is  congenital.  The  anomaly  is  stamped  upon  the 
entire  psychic  and  even  physical  personality  of  the  subject. 

Many  of  these  individuals  have  the  character  and 
tastes  of  the  opposite  sex.  The  little  boy  plays  with  dolls 
and  finds  pleasure  only  in  the  society  of  girls.  Later  on  the 
same  feminine  tendencies  persist,  and  the  patient  secretly 
abandons  himself  to  them.  We  also  often  meet  with  men, 
apparently  normal,  who  in  their  privacy  dress  themselves  in 
female  attire,  cover  themselves  with  laces,  or  passionately 
indulge  in  feminine  employments,  as  sewing,  embroidery, 
etc. 

Physically  certain  anomalies  are  noted  which  resemble 
the  normal  characteristics  of  the  feminine  organism:  con- 
siderable development  of  the  breasts  and  hips,  absence  of 
the  beard,  rounded  shape  of  the  neck,  etc.  Occasionally 
we  observe  a  more  or  less  marked  degree  of  pseudo-her- 
maphroditism. 

The  opposite  anomalies  are  encountered  in  the  female 
sexual  invert:  masculine  features,  beard,  masculine  voice, 
etc. 

Some    inverts    may    have    normal    sexual    intercourse, 


NOMADISM  227 

but  they  derive  no  satisfaction  from  it,  and  always  feel 
an  attraction  for  the  homologous  sex;  often  they  marry, 
hoping  thus  to  cure  their  infirmity,  but  their  attempt  is 
never  successful. 

Nomadism.^ — The  nomadic  tendency  is  present  in  most 
of  us  in  some  degree  and,  as  all  know,  is  in  certain  races  so 
pronounced  as  to  govern  their  mode  of  existence  and  social 
organization.^  In  persons  in  whom  the  wandering  impulse 
is  much  stronger  than  the  average  it  is  still  to  be  judged  for 
practical  purposes  as  being  within  normal  limits,  provided 
it  has  not  the  effect  of  breaking  down  social  adjustment,  but 
leads  merely  to  special  choice  of  occupation,  as  in  many  cases 
of  explorers,  sailors,  railroad  employees,  travelling  salesmen, 
etc. 

Inhibition  of  the  wandering  impulse  sometimes  fails  in 
cases  of  mental  deficiency,  epilepsy,  dementia  praecox,  and 
manic-depressive  psychoses.  Such  failure  may  be  periodic, 
corresponding  with  psychotic  attacks  and  resulting  in 
nomadic  episodes  separated  by  normal  intervals  of  months 
or  years;  or  it  may  be  permanent  owing  to  chronicity  of  the 
underlying  mental  disorder. 

There  are,  however,  cases  in  which  mental  deficiency, 
epilepsy,  psychotic  disease,  or  mental  deterioration  cannot 
be  demonstrated  and  in  which,  nevertheless,  the  nomadic 
impulse  is  in  such  degree  imperative  as  to  lead  to  a  tramp 
existence  and  constant  aimless  wandering  precluding  all 
possibility  of  continued  occupation.  These  are  the  cases 
included,  in  the  group  of  constitutional  psychopathic  states. 

Such  individuals  travel  on  foot,  in  freight  cars,  as  stow- 
aways on  steamers.     They  visit  the  most  distant  parts  of  the 

^C.  B.  Davenport.  Nomadism,  or  the  Wandering  Impulse,  with 
Special  Reference  to  Heredity.  Washington,  1915. — R.  Meunier.  Les 
vagabonds  et  la  vagabondage.  Rev.  mod.  de  med.  et  de  chir.,  1908. — 
A.  Joffroy  and  R.  Dupouy.  Fugues  et  Vagabondage.  Paris,  1909. — 
E.  Stier.  Wandertrieb  und  pathologisches  Fortlaufen  bei  Kindern. 
Samml.  zwangl.  Abh.  z.  Neuro-  und  Psychopath,  des  Kindersalters. 
Vol.  I,  1913. 

2  M.  Gaster.     Gipsies.     Encyclopaedia  Britannica,  11th  edition. 


228         CONSTITUTIONAL  PSYCHOPATHIC  STATES 

country  or  even  of  the  world.  They  work  only  enough  to 
keep  themselves  supplied  with  food  to  live  on  and  clothes  to 
cover  them.  Not  infrequently  they  find  themselves  forced 
to  beg,  steal,, or  trespass  on  private  property  for  a  sheltered 
place  to  spend  a  night. 

They  seldom  stay  long  in  one  place — perhaps  not  more 
than  a  few  hours;  yet,  when  about  to  leave,  it  matters  little 
to  them  where  they  go,  as  long  as  they  move.  A  tramp 
starting,  say,  from  Chicago  to  go  to  Seattle,  might  readily 
change  his  plan  upon  invitation  from  another  to  accompany 
him  to  New  Orleans,  even  if  it  were  the  case  that  he  had  just 
come  from  there. 

Pathological  nomads  are  seldom  able  to  give  a  rational 
reason  for  their  wanderings.  Most  frequently  they  say 
it  is  "  to  see  something  of  the  world."  But  in  reahty  they 
hardly  ever  interest  themselves,  in  the  manner  of  tourists, 
in  the  noteworthy  sights  of  the  places  they  visit. 

Although  generally  without  education  or  culture,  they 
are  apt  to  acquire  in  their  wanderings  much  detailed  geo- 
graphical information  of  a  certain  kind — distances,  roads, 
train  schedules,  climatic  conditions,  local  customs;  and 
those  whose  wanderings  extend  to  foreign  countries  acquire 
a  smattering  of  many  foreign  languages, 


CHAPTER  IV 

DEMENTIA  PRiECOX 

Under  the  name  hebephrenia,  Hecker,  inspired  by  his 
preceptor,  Kahlbaum,  described  a  psychosis  which  develops 
by  predilection  at  the  age  of  puberty  and  which  terminates 
in  a  peculiar  state  of  mental  deterioration. 

Later  KraepeHn  extended  the  views  of  Hecker  and 
added  to  this  group  catatonia,^  which  had  previously  been 
considered  an  independent  affection,  and  paranoid  dementia, 
which  included  the  majority  of  delusional  states  then 
commonly  assigned  to  the  vast  and  ill-defined  group  of 
paranoias.  This  fusion  resulted  in  a  new  morbid  entity: 
dementia  prcecox. 

As  we  shall  see  later  on,  dementia  praecox  cannot  be 
defined  either  by  the  age  at  which  it  occurs  or  by  the  rapidity 
with  which  it  develops.  Its  specific  element  lies  in  the  sum 
of  the  psychic  changes,  affecting  the  emotions,  the  will, 
and  association  of  ideas.  Generally  these  changes  are  per- 
manent and  constitute  the  mental  deterioration  which 
is  the  most  common  outcome  of  the  disease.  In  some 
cases  these  changes  may  recede  either  temporarily  or  even 
permanently. 

Dementia  praecox  appears  in  many  forms  that  are 
difficult  to  classify.  In  Germany,  fol  owing  Kraepelin, 
three  principal  forms  are  distinguished:  hebephrenia,  cata- 
tonia, and  paranoid  dementia.  Delusional  types  of  hebe- 
phrenia resemble  paranoid  dementia  so  closely  that  it  is 
often  impossible  to  determine  to  which  of  these  groups  a 
given  case  should  be  assigned.    It  seems  more  convenient  for 

^  Kahlbaum.     Die  Katatonie  oder  das  Spannungsirresein,  1894. 

229 


230  DEMENTIA  PRECOX 

practical  purposes  to  describe  separately  the  following  three 
forms :  simple  dementia  prsecox  without  delusions ;  dementia 
praecox  of  catatonic  form;  and  dementia  prsecox  of  delusional 
form. 

We  shall  study  first  the  psychic  and  somatic  symptoms 
that  are  common  to  all  forms. 

SYMPTOMS   COMMON   TO   ALL   FORMS 

Psychic  Symptoms.^ — All  psychic  functions  are  not 
equally  affected.  While  orientation  and  memory  are  often 
preserved  or  but  Mttle  affected,  attention,  association  of  ideas, 
the  emotions,  and  the  reactions  are  always  markedly  involved. 

Lucidity  and  Orientation. — These  very  frequentlj^  remain 
intact,  although  the  appearance  of  the  patients  would  scarcely 
lead  one  to  think  so.  Many  patients  appear  to  be  ignorant 
of  what  occurs  about  them,  yet  they  will  give  rational  and 
correct  replies  to  questions  concerning  the  date,  their  sur- 
roundings, and  even  the  important  events  of  the  day.  We 
shall  return  to  this  question  in  connection  with  the  study 
of  catatonia. 

Memory. — Like  lucidity,  memory  is  but  slightly  affected, 
at  least  in  the  majority  of  cases  for  a  considerable  number 
of  years.  Old  impressions  remain  well  defined,  and  the 
knowledge  acquired  during  youth  and  childhood  is  often 
astonishingly  well  preserved.  An  old  asylum  inmate,  a 
typical  case  of  dementia  prsecox,  who  had  been  in  the  insti- 
tution for  fifteen  years,  was  still  able  to  name  without 
hesitation  and  in  their  proper  succession  all  the  French  rulers 
from  the  time  of  Clovis. 

Actual  occurrences  unpress  themselves  quite  durably 
upon  the  memory.  Many  patients  are  able  to  relate  events 
that  have  taken  place  since  their  commitment,  and  can  often 
even  name  the  physicians  and  attendants  who  have  followed 
each  other  on  the  service  during  several  years. 

1  Masselon.  Psychologic  des  dements  precoces.  These  de  Paris, 
1902. 


SYMPTOMS  231 

However,  when  the  affection  is  of  long  standing  it  is  rare 
for  the  memory  not  to  have  become  impaired  to  some 
extent.  Anterograde  amnesia  is  the  first  to  appear;  the 
power  of  fixation  becomes  diminished.  Retrograde  amnesia 
appears  later  and  is  usually  less  marked.  Little  by  little 
old  impressions  grow  fainter  and  may  even  become  entirely 
effaced. 

Atteyition. — This  faculty  is  always  weakened.  Any 
labor  requiring  some  degree  of  concentration  becomes  im- 
possible. 

Association  of  Ideas. — These  are  sluggish  and  often 
occur  without  any  apparent  connection,  giving  rise  to  speech 
which  may  reach  the  extreme  limits  of  incoherence.  We  have 
given  an  example  of  such  speech.^  These  incoherent  phrases 
are  uttered  quietly  and  without  the  volubility  which  charac- 
terizes flight  of  ideas  of  the  maniac.  On  superficial  exami- 
nation this  phenomenon  may  create  the  impression  of  a 
profound  state  of  dementia  or  mental  confusion,  which  in 
realit}^  does  not  exist.  The  patient  whose  incoherent  speech 
we  have  quoted  as  an  example  is  perfectly  oriented  and  pos- 
sesses good  memory. 

The  affectivity  and  the  reactions  are  greatly  impaired 
from  the  beginning.  Indifference  constitutes  an  early  and 
very  prominent  symptom  of  dementia  prsecox.  The  patient 
takes  no  interest  in  anything,  expresses  no  desires,  makes  no 
complaints.  Often  even  hunger  determines  no  reaction.  If 
the  patient  is  accidentally  forgotten  at  meal  time  he  evinces 
no  surprise  a,nd  makes  no  protest.  As  in  all  conditions  of 
dementia,  this  disorder  of  affectivity  is  not  a  conscious  one. 

Occasionally,  especially  at  the  onset  of  the  illness,  this 
habitual  state  of  indifference  is  interrupted  by  explosions  of 
anxiety  or  of  anger,  for  which  there  is  often  no  apparent 
cause. 

A  priori  the  emotional  indifference  of  dementia  praecox 
would  be  expected  to  lead  to  a  reduction  of  the  voluntary  and 

^  See  page  51. 


232"  DEMENTIA  PRECOX 

normal  reactions.  Observations  upon  patients  show  this> 
indeed,  to  be  the  case. 

On  the  other  hand,  the  automatic  reactions  are  often 
exaggerated.  They  manifest  themselves  under  all  the  forms 
described  in  Part  I  of  this  Manual:  pathological  suggesti- 
bility, negativism,  impulsiveness  (stereotypy  of  movements 
and  of  attitudes,  verbigeration,  grimaces,  unprovoked  laugh- 
ter, etc.). 

Mental  Deterioration. — When,  as  is  most  often  the 
case,  the  disorder  of  attention,  the  sluggish  formation  of 
associations  of  ideas,  and  the  impairment  of  affectivity  and 
of  the  will,  or  in  other  words,  when  all  the  symptoms  which  we 
have  described  above  have  become  definitely  established, 
we  have  mental  deterioration. 

The  degree  of  deterioration  is  variable.  In  some  cases 
it  apparently  affects  the  psychic  functions  to  so  pronounced 
a  degree  that  all  mental  activity  seems  to  have  disappeared, 
and,  from  this  point  of  view,  the  patient  cannot  be  distin- 
guished from  an  idiot  or  from  an  advanced  general  paralytic. 
Such  cases  are  exceptional,  and  often  enough  the  dementia 
is  much  less  complete  than  it  appears  to  be  from  a  superficial 
examination,  as  is  shown  by  the  following  case: 

Theresa  C,  formerly  a  school  teacher,  at  present  (1905)  a  patient 
at  the  Clermont  Asylum,  aged  thirty-four  years.  The  disease  came 
on  at  the  age  of  twenty-five.  For  several  years  this  patient  has  lived 
in  a  state  of  apparently  complete  unconsciousness,  incapable  of  carry- 
ing out  the  simplest  commands  or  answering  the  most  elementary 
questions.  The  facial  expression  is  silly.  The  patient  spends  most 
of  her  time  sitting  in  a  chair  or  wandering  about  the  court-yard,  talking 
incoherently,  her  utterances  showing  marked  stereot3'^py.  The  word 
"  mystery  "  keeps  recurring  in  the  manner  of  a  Leitmotiv:  "  To  digest 
the  nature  of  mystery,  Claude  of  mystery,  Matthew  of  mystery,  Joseph 
of  mystery.  It  is  a  conflagration,  it  is  a  petticoat,  it  is  an  oblation, 
resurrection,  when  will  you  wake  up  liVe  the  brutes.  Mystery,  of 
mystery,  forty-eight  of  mystery,"  etc.  Totally  indifferent  to  every- 
thing, she  manifests  not  the  slightest  emotion  when  spoken  to  about 
her  family,  or  when  offered  her  release.  She  is  filthy  in  her  habits. 
And  yet,  when  a  pen  is  put  in  her  hand  she  will  write  disconnected  words 
or  fragments  of  sentences  without   a  single  orthographical  error.     No 


SOMATIC  DISORDERS  233 

example  could  illustrate  more  clearly  the  dissociation  which  charac- 
terizes dementia  precox  in  which  total  ruin  of  some  faculties  is  com- 
patible with  perfect  conservation  of  knowledge  acquired  previously. 

Somatic  Disorders.^— These  are  present  in  all  three 
forms  of  the  disease,  though  they  are  perhaps  most  marked 
in  the  catatonic  form. 

Motility. — The  disorders  of  motility  consist  in  hemi- 
plegias and  monoplegias  that  are  slight  and  of  short  dm^a- 
tion;  convulsive  hysteriform  or  epileptiform  seizures;  and 
fainting  spells.  The  contractures  often  observed  are  usually 
the  consequence  of  negativism. 

Sensibility. — One  must  be  guarded  against  attributing 
the  absence  of  reaction  to  pricking,  which  results  from 
negativism,  to  ansethesia.  True  disorders  of  sensibility  are, 
however,  far  from  being  exceptional.  They  are  often  uni- 
lateral, as  in  hysteria.  Other  hysteriform  symptoms  of  the 
same  order  are  als3  encountered:  tender  areas,  clavus,  globus 
hystericus,  etc. 

Tendon  Reflexes. — Sometimes  diminished  or  abolished, 
much  more  frequently  exaggerated. 

Pupils. — Their  disorders  are  frequent  but  variable: 
inequality,  mydriasis,  sluggish  reaction,  the  phenomenon 
of  Pilcz,  i.e.,  contraction  of  the  pupils  on  forcible  closure  of  the 
eyelids.  This  phenomenon  is  analogous  to  the  following 
one,  which  was  observed  at  the  same  time,  independently,  by 
Pilcz  and  by  Westphal:  "If  the  patient  attempts  to  shut 
his  eye  while  his  effort  is  opposed  by  the  examiner  who  holds 
the  lids  apart  forcibly  with  the  fingers,  a  contraction  of  the 
pupil  takes  place  while  the  eyeball  is  rolled  upward  and  out- 
ward." 2 

The  pupillary  disorders  often  undergo  fluctuations 
corresponding  to  those  of  the  mental  condition.  We  recall 
a  case  of  catatonia  in  which  the  intensity  of  the  stupor  deter- 

^  Seriexix    et    Masselon.     Les    troubles    physiques  chez   les    dements 
precoces.     Soc.  med  psych.,  June,  1902. 
2  Pilcz.     Revue  tieurologique,  1900,  No.  13. 


234  DEMENTIA  PR.ECOX 

mined,  as  it  were,  the  degree  of  mydriasis.  As  the  stupor 
disappeared  the  pupils  reassumed  their  normal  size. 

Circulatory  Apparatus. — Vasomotor  disorders  causing 
oedema,  cyanosis  of  the  extremities,  and  dermatographia 
are  frequent.     Sometimes  the  pulse  is  slowed. 

The  temperature  may  be  subnormal  (Kraepelin)  .^ 

Digestive  Tract. — Indigestion,  anorexia,  and  constipation 
are  often  found,  especially  during  the  acute  period.  The 
development  of  mental  deterioration  is  occasionally  marked 
by  boulimia. 

Urinary  Apparatus. — Sometimes  there  is  polyuria,  at 
other  times,  on  the  contrary,  oHguria.  The  changes  in 
the  composition  of  the  urine  are  but  little  known.  A 
diminution  of  urea  and  an  increase  of  chlorides  have  been 
found. ^ 

Secretions. — We  know  nothing  of  the  disorders  of  the 
.secretions  excepting  that  of  saliva,  which  in  some  cases 
is  greatly  increased. 

General  Nutrition. — Its  changes,  though  undoubtedly 
of  great  importance,  are  as  yet  but  little  known.  The 
weight  is  reduced  in  the  acute  stages,  but  rises  again  during 
the  quiet  periods.  Some  precocious  dements  present  a 
remarkable  degree  of  corpulence. 


A.       SIMPLE    DEMENTIA   PRECOX 

In  this  form  the  symptoms  are  reduced  to  phenomena 
of  mental  deterioration  together  with  more  or  less  pro- 
nounced changes  in  disposition. 

The  07iset  is  almost  always  insidious,  and  it  is  usually 
impossible  to  determine  even  approximately  its  date.  A 
subject  previously  affectionate,  active,  intelligent,  even 
brilliant,  becomes  indifferent,  indolent,  and  distracted.     He 

1  Lehrbuch  der  Psychiatrie,  7th  edition,  Vol.  II,  p.  190. 
^  Dide  et  Chenais.     Recherches  urologiques  et  hematologiques  dans 
la  demence  precoce.     Ann.  med.  psych     1902, 


SIMPLE  FORM  235 

is  weary  of  everj^thing,  of  play  as  well  as  work.  He  ceases 
to  acquire  new  ideas,  or  to  coordinate  those  which  he  has 
acquired  previously,  so  that  his  general  stock  of  ideas  becomes 
more  and  more  limited. 

Nervous  sjanptoms  (headache,  insomnia,  hysteriform 
disturbances)  or  constitutional  symptoms  (anorexia,  loss  of 
flesh)  are  frequent. 

In  the  mild  forms  the  disease  is  often  unrecognized. 
The  symptoms  of  mental  deterioration  pass  for  "  negligence  " 
or  ''  lack  of  ambition."  Such  cases  occur  much  more  fre- 
quently^ than  is  commonly  known. 

The  following  lines  from  a  letter  addressed  by  a  principal 
of  a  school  to  the  parents  of  one  of  his  pupils  are  very  signif- 
icant from  this  point  of  view: 

"  As  you  can  see,  the  marks  of  M  L.  are  no  better  than  those 
for  the  preceding  term,  far  from  it.  This  pupil  pays  no  attention  to 
his  duties,  which  three-fourths  of  the  time  are  left  unfinished;  he 
no  longer  takes  the  trouble  of  learning  his  lessons.  In  the  class  room 
and  at  his  studies  he  spends  most  of  his  time  dreaming.  It  is  evident 
that  he  cares  nothing  for  his  work.  His  professors  no  longer  recognize 
in  him  the  former  studious  pupil.  It  seems  that  even  the  approaching 
examinations  do  not  affect  his  indifference.  When  it  is  pointed  out 
to  him  that  he  is  hkely  to  fail,  he  promises  vaguely  to  be  more  diligent, 
but  one  can  see  that  he  has  no  firm  determination.  The  comments 
and  suggestions  in  the  letters  of  his  parents  no  longer  have  any  effect 
on  him.  .  .  .  Formerly  so  jolly  and  so  full  of  good  humor,  he  has 
become  quite  unsociable.  He  does  not  seem  to  be  pleased  except 
when  alone.  When,  by  way  of  exception,  he  joins  his  comrades  in 
conversation  or  in  play,  he  soon  leaves  them,  often  after  quarreling 
with  them  over  some  absurd  trifle.  .  .  .  Lately  he  has  been  com- 
plaining of  insomnia  and  headache.  We  have  had  the  physician 
see  him,  but  he  has  found  nothing  serious  and  has  merely  prescribed 
rest." 

M.  L.  IS  to-day  a  true  dement.  He  lives  with  his  parents 
and  is  at  best  able  to  do  only  simple  manual  work.  For  a 
long  time  he  showed  some  irritability.  Now  he  has  become 
totally  indifferent. 


236  DEMENTIA  PRECOX 


B.       CATATOXIA 

Onset. — Prodromata  are  almost  constant;  they  possess 
no  specific  features:  change  of  disposition,  inaptitude  for 
work,  insomnia. 

Often  the  sjuiptoms  of  melanclioUa  open  the  series  of 
grave  phenomena.  In  themselves  they  present  no  patho- 
gnomonic features,  but  consist  merely  in  a  state  of  depres- 
sion or  psychic  pain  which  may  be  associated  with  delusions 
and  hallucinations. 

Soon  the  catatonic  phenomena  proper  appear;  they 
may  occur  also  at  the  onset  without  being  preceded  by  the 
period  of  depression  mentioned  above.  They  depend  upon 
a  disorder  of  affectivity,  indifference,  and  a  disorder  of  the 
reactions,  disappearance  of  the  normal  icill  associated  with 
exaggeration  of  the  mental  aidomati&m.  Clinically  they  appear 
in  two  principal  forms:  catatonic  excitement  and  catatonic 
stupor. 

Catatonic  Excitement. — Sometimes,  especially  at  the 
beginning,  it  simulates  an  attack  of  confusional  psychosis 
or  of  mania:  disordered  movements,  incoherent  speech, 
impulsive  reactions.  Soon,  however,  the  nature  of  the  sjonp- 
toms  becomes  more  definite  and  the  peculiar  characteristics 
of  catatonic  excitement  appear.  Its  principal  featm^es  are 
as  foUows: 

(1)  Catatonic  excitement  is  free  from  any  emotion; 

(2)  It  is  not  influenced  by  external  impressions; 

(3)  It  is  not,  at  least  in  the  majority  of  cases,  governed 
by  definite  delusions; 

(4)  It  is  monotonous  (stereotyped  movements,  ver- 
bigeration; . 

In  other  words,  the  reactions  in  catatonic  excitement 
attain  the  extreme  limits  of  automatism. 

The  spells  of  excitement  occur  without  cause,  in  an 
impulsive  and  unexpected  manner.  The  patient  performs 
most  singular  and  at  times  most  dangerous  acts  'uithout 
being  able  to  furnish  any  explanation  for  his  conduct  even 


CATATONIC  FORM  237 

when  the  attack  has  passed  and  has  left  in  his  mind  a  clear 
recollection  of  all  that  he  did.  A  catatonic,  perfectly  com- 
posed an  instant  before,  leaves  his  bed,  seizes  a  glass  and 
throws  it  violently  at  the  head  of  his  neighbor.  Another 
breaks  to  pieces  a  thermometer  imprudently  left  in  his 
possession.  A  third  calls  loudly  for  a  drink  of  water  while 
holding  in  his  hand  a  glass  filled  to  the  brim.  Some  display 
for  weeks  or  months  suicidal  tendencies  without  there  being 
any  depressive  ideas  to  account  for  them. 

The  movements,  attitudes,  and  conversation  present 
stereotypy  and  verbigeration.  Often  the  patients  assume 
an  affected  or  dramatic  air.  Their  gestures,  manners,  and 
fantastic  dress  frequently  survive  the  period  of  excitement 
and  persist  through  the  quiet  periods  and  the  terminal 
dementia.  Some  patients  will  hop  on  one  foot  for  months 
instead  of  walking;  others  will  invariably  respond  to  all 
questions  by  the  same  phrase;  still  others  will  not  eat  their 
food  without  first  mixing  it  up  into  a  disgusting  mess;  others, 
again,  will  walk  back  and  forth  on  a  short  path  all  day  long, 
taking  alternately  a  certain  number  of  steps  forward  and 
the  same  number  backward.  Such  examples  could  be 
multiplied  indefinitely.  Most  frequently  these  peculiari- 
ties in  the  conduct  of  the  patient  are  purely  automatic  and 
remain  inexplicable.  They  are  usually  not  dependent  upon 
delusions.  Their  origin  lies  in  a  perversion  of  the  reactions, 
and  not  in  any  disorder  of  ideation  or  of  perception.  Al- 
though delusions  and  hallucinations  are  not  invariably 
absent  in  catatonia,  as  is  insisted  upon  by  Tschisch,^  they  are 
too  rare  to  explain  the  anomalies  of  the  reactions,  which 
are  constant. 

Catatonic  Stupor. — This  may  follow  a  period  of  depres- 
sion or  one  of  catatonic  excitement,  or  it  may  be  primary, 
constituting  the  onset  of  the  disease. 

In  its  true  sense  the  term  "'  stupor  "  implies  the  exist- 
ence   of   a    profound    disorder    of    consciousness.     In    this 

1  Tschisch.  Die  Kalatonie.  A  Russian  work  abstracted  in  Allgem. 
Zeitschr.  fur  Psychiatrie,  1900. 


238  DEMENTIA  PRECOX 

connection,  however,  the  word  is  used  in  a  different  sense. 
As  a  matter  of  fact  lucidity  is  but  sHghtly  if  at  all  impaired 
in  the  catatonic.  Impressions  of  the  external  world  are 
perceived  almost  normally.  Very  frequently  the  patient, 
though  seemingly  unconscious  of  his  surroundings,  relates, 
after  the  stuporous  attack  has  passed,  with  surprising  pre- 
cision the  facts  which  would  seem  to  have  totally  escaped  his 
observation. 

In  spite  of  appearances  catatonic  stupor  is  therefore 
not  the  result  of  an  intellectual  disorder  proper,  but,  like 
catatonic  excitement,  of  a  disorder  of  the  will. 

Automatism  of  the  reactions  is  met  with  in  three  forms, 
which  we  have  already  mentioned:  negativism,  stereotypy, 
and  pathological  suggestibility. 

Negativism  is  manifested  in  simple  acts,  such  as  move- 
ments of  a  limb,  as  well  as  in  complex  acts,  such  as  eatmg, 
dressing,  etc.  The  patient  fails  to  react  to  stimuh  either 
from  the  external  world  or  from  his  own  organism.^  An 
order  given  is  not  executed.  Pricking,  even  when  deep,  pro- 
duces no  movement,  not  because  it  is  not  felt,  but  because 
voluntary  reaction  is  annihilated.  Hunger  produces  no 
reaction.  The  urine  accumulates  in  the  bladder,  saliva  in 
the  mouth,  fsecal  matter  in  the  rectum  without  there  being 
any  true  paralysis. 

Two  particularly  interesting  forms  of  negativism  are 
mutism  and  refusal  of  food.  Either  symptom  may  persist 
for  a  long  time  without  interruption  and  each  may  present 
very  diverse  characteristics. 

Stereotypy  is  seen  in  the  attitudes  and  in  the  physiognomy. 

Certain  patients  assume  very  singular  positions :  extreme 
flexion  of  the  limbs,  a  squatting  position,  the  elbows  upon 
the  knees,  the  head  drawn  back,  etc. 

The  physiognomy  of  the  patient  is  often  distorted  by 
grimaces.  The  lips  are  contorted  in  a  kind  of  grin,  or  pro- 
truded,  as  though  the   patient  were  making  faces.     The 

*  Stoddart.  Anesthesia  in  the  Insane.  The  Journal  of  Mental 
Science,  Oct.,  1899. 


CATATONIC  FORM  239 

eyes  may  be  closed  tightly.  These  phenomena  may  persist 
for  months  or  years.  Almost  always,  at  least  in  the  begin- 
ning, they  disappear  during  sleep. 

Pathological  suggestibility  often  alternates  with  nega- 
tivism. Certain  catatonics  retain  any  attitude  in  which 
they  may  be  placed,  even  the  most  uncomfortable  (catalep- 
toid  attitudes).  Incapable  of  making  their  toilet  they 
submissively  allow  themselves  to  be  washed,  combed,  and 
dressed.  Many  become  filthy  and  soil  and  wet  themselves 
unless  taken  to  the  toilet  at  regular  intervals.  Sometimes 
a  single  impulse  suffices  to  start  the  subject  and  make 
him  accomplish  in  a  sort  of  mechanical  manner  some  habitual 
act  or  even  series  of  acts:  once  seated  at  the  table  with  his 
plate  filled  in  front  of  him,  he  may  eat  like  a  normal  person. 

Echolalia  and  echopraxia — phenomena  which  are  also 
dependent  upon  suggestibility — are  not  infrequent. 

Like  catatonic  excitement,  catatonic  stupor  is  essentially 
free  from  emotion. 

The  following  case  is  a  good  illustration  of  catatonic 
excitement  and  catatonic  stupor: 

Adrienne  P.,  patient  at  the  St.  Anne  Asylum,  corset  maker,  twenty- 
five  years  old  at  the  onset  of  her  illness. — Heredity:  paternal  grand- 
father died  at  the  age  of  sixty  years  of  senile  dementia;  father  is  an 
alcoholic,  has  been  committed  twice;  paternal  aunt  committed  sui- 
cide.— The  patient  began  to  walk  and  speak  very  late  in  childhood; 
menstruation  appeared  at  the  age  of  seventeen,  has  been  regular 
but  painful.  She  showed  no  abnormality  in  intelligence  or  dis- 
position.— At  nineteen,  pleurisy.  At  twenty-four,  during  a  sojourn 
in  London,  a  severe  attack  of  scarlet  fever  with  pronounced  albumi- 
nuria; patient  was  sick  three  and  a  half  months ;  convalescence  lasted 
two  months.  Since  then  (fall  of  1897),  the  relatives  noticed  a  change 
in  the  mental  condition  of  the  patient  from  the  letters  which  she  wrote 
home.  On  her  return  to  France  Adrienne  was  gloomy,  irritable, 
apathetic.  She  refused  to  work  and  often  even  to  rise  in  the  morning. 
Complete  loss  of  appetite,  headache.  Much  worried  about  her  health, 
she  consulted  several  physicians  but  with  no  appreciable  result. 

On  October  20,  18^8,  acute  symptoms  set  in  in  the  form  of  dis- 
orders of  perception.  The  people  are  "  droll,"  the  dishes  served  in 
the  restaurant  are  "  droU,"  life  is  "  droll  "  and  "  absurd."     At  the 


240  DEMENTIA  PRiECOX 

same  time  hallucinations  of  vision  appeared:  the  patient  saw  men 
following  her,  also  ghosts  and  stars.  On  October  26  she  started  out 
to  go  to  her  sister  who  lived  in  the  suburbs  of  Paris;  failing  to  find 
her  she  walked  at  random  and  wandered  around  the  country  for  two 
days  and  two  nights.  She  was  found  walking  along  a  railroad  track, 
her  hair  undone,  her  clothes  in  disorder;  they  arrested  her  and  took 
her  to  the  Corbeil  Hospital  where  she  remained  eight  days  in  complete 
mutism.'  On  her  return  to  her  mother  her  mutism  disappeared,  but 
she  gave  no  explanation  of  what  she  did,  telling  simply  that  she  had  seen 
things  which  frightened  her:  terrible  men  and  animals.  For  some  time 
she  remained  relatively  quiet,  but  depressed  and  intractable.  She 
refused  to  see  a  physician,  though  her  mother  begged  her  to  do  so. 
On  the  night  of  November  24  she  suddenly  became  greatly  excited, 
cried,  gesticulated,  and  uttered  incoherent  remarks  some  of  which  were 
suggestive  of  hallucinations:  she  spoke  of  men  following  her  and  of 
saints  whom  she  saw.     She  tried  to  throw  herself  out  of  the  window. 

On  being  brought  to  the  clinic  on  November  28  she  was  in  almost 
complete  mutism.  To  all  questions  put  to  her  she  responded  by 
outlandish  gestures  and  grimaces  bearing  no  reference  to  the  questions. 
On  being  asked  to  write  she  tore  the  piece  of  paper  which  was  offered 
her. 

On  December  1,  at  the  occasion  of  a  visit  from  her  mother,  Adrienne 
came  out  of  her  mutism  but  her  remarks  were  incoherent.  "  She 
cannot  see,  she  can  see  very  clearly.  .  . ' .  It  is  Alfred,  it  is  Martin 
speaking  to  her.  .  .  .  They  are  not  saying  anything."  It  was  very 
difficult  to  tell  whether  she  really  had  hallucinations. 

Toward  the  evening  she  became  totally  estranged  from  the  exter- 
nal world.     She  no  longer  responded  to  any  question. 

Spells  of  excitement  and  of  stupor  have  since  then  followed  each 
other  without  any  regularity,  presenting  respectively  the  character- 
istic features  of  catatonic  excitement  and  of  catatonic  stupor. 

The  excitement  is  purely  automatic.  The  same  movements  are 
constantly  repeated  monotonously  and  aimlessly.  For  hours  at 
a  time  the  patient  goes  through  peculiar  and  incomprehensible  gestures, 
striking  the  floor  alternately  with  the  right  foot  and  with  the  left 
foot,  and  extending  her  arms  and  clinching  her  fists  in  a  threatening 
manner  but  never  striking  anyone.  She  stands  up  in  her  bed  in  a 
dramatic  attitude,  draped  with  the  blanket,  and  frozen,  so  to  speak, 
in  that  position,  uncomfortable  as  it  is.  In  her  attacks  of  excitement 
she  displays  considerable  physical  strength.  On  May  25,  1900,  she 
made  a  steady,  persistent  attempt  to  leave  her  bed  and  get  out  of  the 
dormitory;  her  eyes  were  shut,  her  expression  apathetic,  and  she 
uttered  not  a  word  or  a  cry.  Several  nurses  held  her  back  with 
difficulty. 

Her    utterances    show    either    incoherence    or    verbigeration.     On 


CATATONIC  FORM  241 

January  15,  1900,  sho  stood  up  in  her  bed  and  sang  for  several  hours: 
"  The  baker's  wife  has  money,"  etc.  On  May  23,  of  the  same  year, 
she  kept  repeating  during  several  hours  without  interruption  "  Hail 
Mary,"  etc. 

She  shows  marked  negativism.  When  spoken  to  she  vriU.  give  no 
response,  showing  absolute  mutism;  she  resists  systematically  aU 
attempts  at  passive  movement:  to  open  her  mouth,  to  flex  an  ex- 
tended limb,  or  vice  versa.  The  command  to  open  her  eyes  results 
immediately  in  a  sjiasm  of  the  orbicularis  muscle.  Refusal  of  food 
is  at  times  complete,  and  then  the  patient  has  to  be  tube-fed;  at 
other  times  it  is  partial,  the  patient  taking  only  Uquid  food  which  is 
poured  into  her  mouth  by  means  of  a  feeding  cup  and  which  she  then 
swallows  readily.  On  November  4,  without  any  apparent  reason, 
she  ate  spontaneously  a  piece  of  bread  which  she  took  from  the  table. 
For  two  days  she  thus  took  bread,  cheese,  and  chocolate,  but  per- 
sistently refused  everything  else.  Later  she  relapsed  into  the  former 
state  and  now  takes  none  but  liquid  food  which  has  to  be  poured 
into  her  mouth.  Her  sensibility  appears  to  be  normal,  but  all  reaction 
is  annihilated.  Painful  pricking  with  a  pin  causes  slight  trembling, 
but  no  cry,  nor  any  movement  of  defense. 

In  the  stuporous  phases  the  patient  lies  in  her  bed,  completely 
immobile.  Generally  this  immobihty  is  dominated  by  negativism 
which  is  manifested  by  the  same  traits  as  those  observed  in  her  excited 
phases.  On  several  occasions,  however,  she  has  shown  very  marked 
suggestibility.  Thus  once  she  submitted  readily,  though  passively, 
to  being  dressed  and  taken  to  the  office  of  the  ward  physician.  '^Tien 
standing  she  remains  motionless,  yet  she  will  walk  mechanically  as 
soon  as  she  is  pushed.  T\Tien  invited  to  sit  down,  the  patient  shghtly 
flexes  her  legs  and  makes  a  movement  as  though  starting  to  sit  down, 
showing  that  the  command  is  understood;  yet  she  will  go  no  further, 
but  remains  standing.  When  taken  by  the  shoulder  and  shghtly  pushed 
she  sits  dowTi  without  trouble.  Her  limbs  are  flaccid  and  present  no 
resistance  to  any  passive  movement.  Negativism  persists  only  in  the 
muscles  of  the  mouth  and  ej-^e-lids,  w^hich  remain  closed  and  resist 
being  opened.  Cataleptoid  attitudes  are  rare.  One  was,  however, 
observed  on  October  30,  1900.  The  right  arm  was  held  for  ten  minutes 
in  complete  extension.  On  the  following  day  this  sjonptom  disap- 
peared. 

The  patient  soils  and  wets  her  bed  frequently,  though  not  con- 
stantly, both  during  the  periods  of  excitement  and  during  those  of 
stupor. 

The  general  nutrition  is  profoundly  affected;  the  skin  is  discolored, 
the  hair  is  falling  out,  and  there  is  considerable  emaciation:  from 
December,  1898,  until  May,  1899,  the  patient's  weight  fell  from  94 
to  77  pounds. 


242  DEMENTIA  PRECOX 

In  March,  1901,  the  patient,  considered  as  being  completely  incur- 
able, was  transferred  to  another  institution. 

Save  in  the  rare  cases  in  which  the  disease  terminates  in 
recovery,  the  catatonic  comes  out  of  his  spell  of  excitement 
or  of  stupor  with  more  or  less  mental  deterioration. 

Often  some  of  the  catatonic  phenomena  persist,  thus 
disclosing  the  origin  of  the  dementia:  stereotyped  attitude, 
mannerisms,  verbigeration,  etc. 

The  following  case  illustrates  this  point: 

Suzanne  N.,  patient  at  the  Clermont  Asylum,  at  present  (1904) 
fifty-eight  years  old.  The  disease  came  on  in  1894,  when  the  patient 
was  forty-eight  years  old.  The  clinical  record  in  this  case  shows  an 
affection  develoi)ing  by  alternating  attacks  of  excitement  and  depres- 
sion, with  occasional  mutism  and  refusal  of  food.  For  the  past  several 
years  the  patient  has  been  living  apparently  estranged  from  all  that 
surrounds  her.  She  never  speaks  to  the  physician,  to  the  nurses, 
or  to  any  of  the  other  patients.  She  answers  no  questions,  carries 
out  no  command.  Negativism  is  very  marked.  Any  attempt  to  open 
her  mouth,  shake  hands  with  her,  etc.,  meets  with  absolute  resistance. 
The  patient's  gestures,  actions,  and  utterances  present  all  the  features 
of  stereotypy.  For  hours  she  keeps  repeating  certain  movements, 
which  would  surely  very  soon  tire  out  a  normal  person,  and  which 
consist  in  shaking  both  hands  up  and  down  a  good  deal  like  Uttle 
children  do  in  imitation  of  marionettes.  When  free  she  starts  imme- 
diately for  the  nearest  door,  which  she  tries  to  open,  and,  when  she 
succeeds  in  doing  so,  continues  to  walk  straight  ahead  without  any 
aim.  Yet  if  she  is  tied  in  her  chair,  even  though  it  be  only  with 
nothing  stronger  than  a  woolen  thread,  she  will  not  budge.  When 
the  door  of  the  ward  is  shut  she  is  completely  mute — but  the  instant 
the  door  is  opened,  she  begins  mechanically,  like  a  spring  that  is  sud- 
denly released,  to  repeat  in  a  monotone:  "  Eucharist,  penance,  extreme 
unction,"  or  "  Jesus  Christ,  Holy  Sacrament,"  or  she  recites  from 
beginning  to  end:  "  I  believe  in  God,"  etc.  This  is  kept  up  as  long 
as  the  door  remains  open,  but  ceases  as  soon  as  it  is  shut. 

She  is  very  untidy  in  her  habits,  spilling  her  food  upon  her  dress 
and  often  wetting  her  bed  or  clothes. 

In  spite  of  the  complete  indifference  which  she  shows,  the  patient 
is  perfectly  lucid.  Nothing  that  occurs  about  her  escapes  her  observa- 
tion. During  the  visits  of  her  relatives  her  mutism  disappears  as  by 
magic.  She  converses  readily  and  tells  all  the  gossip  of  the  institution: 
they  had  a  feast  on  mid-Lent,  Mrs.  X.  got  a  new  dress,  etc. 


DELUSIONAL  FORMS  243 

The  disease  often  develops  in  repeated  acute  attacks, 
each,  whatever  be  its  form,  leaving  behind  it  a  more  advanced 
degree  of  mental  deterioration.  Occasionally  attacks  of 
excitement  and  stupor  alternate  with  each  other  with  a  cer- 
tain regularity,  simulating  a  manic-depressive  psychosis. 

C.      DEMENTIA    PRECOX   OF   DELUSIONAL    FORM 

The  prodromata  consist,  as  in  most  psychoses,  in  change  of 
disposition,  insomnia,  and  impairment  of  general  health. 

Schematically  we  may  distinguish  in  the  delusional  form 
of  dementia  prsecox  two  extreme  types  which  are  connected 
by  a  great  many  intermediate  types:  (1)  the  incoherent  type; 
(2)  the  systematized  type. 

(1)  Dementia  Prsecox  with  Incoherent  Delusions. — As 
this  name  indicates,  the  delusions  and  the  numerous  hallu- 
cinations which  usually  accompany  them  follow  each  other 
without  any  connection  or  governing  idea,  and  are  accepted 
by  the  patient  as  they  appear,  without  any  attempt  on  his 
part  to  find  an  explanation  or  interpretation  for  them. 

The  general  character  of  the  delusions  may  be  of  three 
varieties : 

(a)  Depressive  Variety:  Melancholy  delusions  associated 
with  more  or  less  marked  depression  and  hallucinations 
of  a  painful  nature.  Often  ideas  of  persecution  are  added 
to  the  melancholy  ideas,  and  occasionally  they  even  pre- 
dominate. It  is  not  rare  to  encounter,  especially  at  the 
beginning  of  the  disease,  attacks  of  very  pronounced  anxiety, 
suicidal  ideas  and  attempts,  or  violent  tendencies. 

(h)  Maniacal  Variety:  Excitement,  irritability,  morbid 
euphoria,  ideas  of  grandeur  occasionally  associated  with 
ideas  of  persecution,  numerous  hallucinations,  erotic  tenden- 
cies, and  sometimes  a  certain  degree  of  confusion. 

(c)  Mixed  Variety:  The  two  preceding  varieties  are 
seldom  met  with  in  a  state  of  purity.  They  are  almost 
always  combined  with  each  other  in  one  of  two  different 
wavs: ' 


244  DEMENTIA  PR^ECOX 

(1)  States  of  depression  and  those  of  excitement  alter- 
nate without  any  order,  and  mutually  replace  each  other 
every  instant;  in  other  words,  the  delusional  state  is  poly- 
morphous. 

(2)  The  disease  develops  in  three  stages: 

I.  Depression  with  melancholy  delusions; 

II.  Excitement  with  expansive  delusions; 

III.  Dementia. 

Sometimes,  as  in  catatonia,  the  disease  assumes  a  circular 
type.  There  are  recurrent  attacks,  each  consisting  of  a 
phase  of  depression  and  one  of  excitement  and  leaving  behind 
each  time  a  more  pronounced  state  of  deterioration. 

(2)  Dementia  Praecox  with  Systematized  Delusions. — 
This  is  the  type  to  which  the  term  paranoid  dementia  is 
most  applicable.  The  systematization  of  the  delusions 
is  not  equally  accurate  in  all  cases.  Sometimes  it  is  quite 
perfect,  so  that  the  disease  resembles  paranoia.  In  other 
eases  the  systematization  is,  on  the  contrary,  so  imperfect 
that  one  hesitates  to  classify  the  case  as  dementia  praecox 
with  systematized  delusions.  We  have  already  seen  that 
there  exists  between  the  two  delusional  forms  of  dementia 
praecox  an  infinity  of  intermediate  forms. 

Lucidity  is  preserved  except  during  the  transitory 
acute  paroxysms,  which  are  of  frequent  occurrence. 

Hallucinations  are  frequent  and  affect  all  the  senses. 

Dementia  supervenes  after  a  variable  period  of  time, 
which  is  in  some  cases  very  long.  As  it  progresses  the  num- 
ber of  delusions  becomes  more  and  more  limited,  the  hallu- 
cinations diminish  in  frequency  and  in  intensity,  and  the 
reactions  become  weaker  and  weaker.  Often  the  system  of 
delusions  is  reduced  to  one  or  two  morbid  ideas,  crystallized, 
so  to  speak,  and  constituting  a  paranoic  residue  which  remains 
as  the  last  vestige  of  the  delusional  state  originally  charac- 
terizing the  affection.  Neologisms  are  frequent  in  the 
period  of  dementia. 

The  systematized  type  of  delusional  dementia  praecox 
is  met  with  in  three  principal  varieties : 


DELUSIONAL  FORMS  245 

(a)  Perseciitoiy  variety; 

(6)  Melancholic  variety; 

(c)  Megalomaniacal  variety. 

(a)  Persecutory  Variety. — The  delusions  may  either 
appear  rapidly,  after  a  brief  period  of  prodromata,  or,  on 
the  contrary,  they  may  develop  slowly,  accompanied  at 
first  by  false  interpretations  and  only  later  by  hallucina- 
tions. 

The  psycho-sensory  disorders,  hallucinations  and  illu- 
sions, are  constant,  of  an  unpleasant  nature,  and  may 
affect  any  of  the  senses.  Hallucinations  of  the  genital 
sense  are  frequent. 

The  reactions  consist  in  defensive  acts;  these  reactions 
become  gradually  weaker  as  the  dementia  becomes  estab- 
lished. 

The  dementia  is  often  announced  by  disaggregation  of 
the  personaHty,  with  such  symptoms  as  autochthonous 
ideas,  motor  hallucinations,  stealing  and  echo  of  the  thoughts, 
etc.  The  time  of  its  appearance  is  quite  variable.  Multi- 
phcity  of  halluciaations  usually  indicates  a  grave  prognosis 
and  points  to  a  rapid  evolution  toward  mental  deterioration. 

It  is  not  rare  to  note  some  degree  of  excitement  appear- 
ing in  paroxj^smal  attacks. 

(6)  Melancholic  Variety. — At  the  onset  the  melancholy 
ideas  present  no  peculiarity.  There  are  ideas  of  culpability, 
humUity,  ruhi,  etc.,  as  in  involutional  melanchoha  and  manic- 
depressive  psychoses.  Later  they  group  themselves  so  as  to 
form  a  delusional  system  which  persists  until  the  appearance 
of  dementia. 

All  varieties  of  psycho-sensory  disturbances  are  met 
with.  The  most  important  are  motor  hallucinations, 
which  are  of  quite  frequent  occurrence  and  indicate  already 
advanced  psychic  cKsaggregation. 

]Mystic  ideas,  ideas  of  possession,  hypochondriacal  ideas, 
and  ideas  of  negation  are  frequent. 

Attacks  of  anxiety,  common  in  the  beginning,  as  they 
are  in  all  psychoses  in  which  the  depressed  state  predomi- 


24G  DEMENTIA  PRiECOX 

nates,  become  less  and  less  frequent  as  the  peculiar  indiffer- 
ence of  dementia  prsecox  establishes  itself,  and  the  most 
frightful  delusions  often  exist  without  any  emotional  reaction. 
As  in  the  preceding  form,  the  mental  deterioration  often 
takes  a  long  time  to  develop. 

(c)  Megalomaniacal  Variety. — The  ideas  of  grandeur 
may  either  be  primary  or  they  may  follow  a  very  brief 
period  of  ideas  of  persecution.  They  assume  the  most 
varied  forms.  The  patients  claim  to  be  owners  of  immense 
fortunes,  to  be  of  illustrious  descent,  to  possess  remarkable 
talents,  etc. 

The  hallucinations,  which  are  less  numerous  and  less 
constant  in  this  than  in  the  two  preceding  varieties,  are 
always  of  an  agreeable  nature.  The  development  of  de- 
mefitia  is  usually  rapid. 

(d)  Mixed  Varieties. — The  three  preceding  varieties  may 
combine  so  as  to  form  four  principal  mixed  types : 

Type  I:  Period  of  melancholia;  period  of  persecutory 
ideas;  period  of  dementia. 

Type  II:  Period  of  melancholia;  period  of  persecutory 
ideas;  period  of  grandiose  ideas;  period  of  dementia. 

Type  III:  Period  of  melancholia;  period  of  grandiose 
ideas;    period  of  dementia. 

Type  IV:  Period  of  persecutory  ideas;  period  of 
grandiose  ideas;  period  of  dementia. 

The  different  periods  almost  always  overlap;  melan- 
choly ideas  and  ideas  of  persecution,  for  instance,  often 
coexist;  and  the  same  is  true  of  ideas  of  grandeur  and 
ideas  of  persecution. 

We  regret  that  the  space  at  our  disposal  is  so  limited 
as  to  preclude  citing  cases  illustrative  of  all  the  different 
varieties  of  paranoid  dementia.  We  shall  limit  ourselves 
to  the  citation  of  one  case  which  seems  to  have  reached  its 
complete  development  and  which  will  give  the  student  an 
idea  of  paranoid  dementia  with  imperfectly  systematized 
delusions  terminating  in  mental  deterioration. 

Louise  S.,  fifty  years  of  age,  occupation  day  worker.    The  disease 


DELUSIONAL  FORMS  247 

came  on  in  1882.  The  record  of  examination  at  that  time  shows  a 
state  of  depression  with  ideas  of  persecution  and  numerous  hallucina- 
tions. Toward  1886  systematized  delusions  of  persecution  had  de- 
veloped, also  combined  with  hallucinations.  From  1890  to  1892  the 
patient  had  spells  of  extreme  excitement,  caused,  it  seems,  by  auditory 
hallucinations;  in  her  excited  spells  she  made  many  violent  assaults 
on  those  about  her.    Since  1894  the  delusions  lost  their  systematization. 

At  present  the  patient  presents  a  rather  incoherent  delusional 
state,  consisting  of  ideas  of  persecution,  ideas  of  grandeur,  halluci- 
nations of  hearing  and  of  vision,  and  characterized  by  formation  of 
numerous  neologisms. 

The  patient's  persecutors  are  two  in  number:  a  man  and  a  woman. 
They  sleep  in  the  asylum  at  night.  But  they  go  out  every  morning 
and  the  patient  sees  them  wandering  about  in  the  vicinity  of  the 
asylum  (visual  hallucinations).  She  sees  them  "  in  a  by-place,  like 
the  trees  in  the  distance."  AH  that  she  knows  about  their  dress  is  that 
the  woman  wears  a  black  scarf  with  tricolored  stripes  at  the  ends: 
green  and  two  shades  of  red.  Their  name  is  "  Tantan."  As  they 
go  by  they  shout  "  There  are  the  Tantans!  There  are  the  Tantans!  " 
Their  remarks  contain  many  neologisms.  They  complain  of  being 
"  knaified  "  (tied  together)  by  a  cord  which  they  call  "  credamina  ". 
When  they  see  the  peasants  at  work  they  say:  ".We  shall  '  charlott ' 
(stroll  around),  that  will  be  better."  They  pour  out  imprecations  and 
threats  against  the  "  asilette  "  (sanatorium):  "  Nasty  asilette!  .  .  . 
We  shall  founder  the  asOette!  .  .  .  We  shall  open  fire  upon  the  asi- 
lette! "  They  try  to  poison  the  food  of  the  patients,  and  this  spoils 
the  taste  of  the  food  and  causes  symptoms  of  poisoning.  They  call 
the  patient  "  cracked  "  and  threaten  to  kill  her.  But  she  is  not  afraid 
of  them,  as  she  has  authority  over  them,  provided  the  physicians  will 
give  her  the  power.  On  the  thirteenth  of  last  February  she  made  them 
pay  502  francs  which  they  owed  her  for  washing.  They  are  very 
deeply  in  debt;  they  owe  especially  a  great  deal  of  money  to  the  town 
of  Clermont  and  they  are  condemned  to  wander  until  they  have  paid 
off  all  their  debts. 

The  patient's  ideas  of  grandeur  are  much  more  incoherent  than 
those  of  persecution.  The  patient  has  two  existences.  The  dura- 
tion of  the  first — which  preceded  her  birth — is  reckoned  in  centu- 
ries. The  second,  which  is  her  "  minority,"  is  reckoned  as  forty- 
nine  years  (her  real  age).  She  has  assumed  a  fictitious  name: 
Mrs.  Schlem,  nee  Madeleine  Vean  Marcille.  Each  human  being 
coming  from  the  hands  of  God  should,  according  to  her,  bear  a  "  num- 
ber of  creation."  Hers  is  2.511.  Born  in  Alsace  (which  is  correct), 
she  was  brought  up  in  the  land  of  "  Frantz,"  a  country  like  France, 
only  "  more  ancient  and  more  serious,"  governed  at  once  "  by  a 
republic,  a  king,  and  an  emperor."     She  spent  part  of  her  life  in  the 


248  DEMENTIA  PRECOX 

"  Helvandese  "  republic.  She  made  her  living  there  by  manufacturing 
desserts.  Since  then  she  became  the  successor  of  Her  Majesty  "  Anger- 
guma,"  the  queen  of  the  "  Sgoths,"  a  people  living  between  Switzer- 
land S  and  Switzerland  C.  She  has  59  million  francs  which  she  earned 
by  working  as  a  nurse  for  children  and  later  as  a  portress.  Her  wages 
were  3  francs  per  day.  She  was  nurse  for  children  for  four  hundred 
and  seven  years.  The  rest  of  the  time — she  cannot  tell  exactly  the 
number  of  years — she  has  been  working  as  portress,  which  is  still  her 
occupation.  All  her  titles  and  all  her  rights  are  recorded  in  the  "  docu- 
ments of  conviction,"  a  book  which  she  has.  Information  concerning 
this  book  is  to  be  obtained  from  the  one  in  charge  of  the  scullery. 

These  delusions,  though  active,  at  present  produce  no  reaction 
on  the  part  of  the  patient  and  do  not  affect  her  lucidity.  The  patient 
is  quiet  and  is  a  useful  and  intelligent  worker.  She  works  in  the 
dining  room  of  her  ward,  sees  that  the  table  cloth  is  put  on  at  the  proper 
time  and  that  the  slices  of  bread  are  regularly  distributed.  After  meals 
she  helps  to  wash  the  dishes  and  watches  over  the  work  of  her  helpers. 
Between  meals  she  works  in  the  nurses'  kitchen.  On  Sundays  she  writes 
letters  for  other  patients  who  are  unable  to  write.  The  letters  which 
she  composes  are  perfectly  sensible,  and  the  spelling  is  tolerably  good, 
which  indicates  the  conservation  of  a  certain  amount  of  knowledge 
acquired  previously.  But  her  activity  is  always  in  the  same  direction 
in  which 'it  has  been  for  a  number  of  years.  The  supervising  nurse 
reports  that  she  cannot  adapt  herself  to  new  work. 

Her  affections  have  completely  disappeared.  Her  children,  whom 
she  persists  in  calling  her  "  babies,"  paid  her  a  visit  several  years 
ago.  She  recognized  them,  but  received  them  with  absolute  indif- 
ference. She  shows  no  attachment  to  anyone  about  her.  Whenever 
any  nurse  or  patient  leaves  the  institution,  she  simply  says:  "  Another 
will  soon  come  in  her  place." 

Delire  Chronique  a  Evolution  Systematique. — Isolated 
by  Magnan  from  the  poorly  defined  group  of  paranoic 
conditions,  delire  chronique  presents  a  striking  analogy  to 
certain  forms  of  dementia  prsecox,  which  fact  led  Krae- 
pelin  to  include  it  under  the  heading  of  paranoid  dementia. 
Conforming  to  French  usage,  we  shall  describe  it  as  a  sepa- 
rate clinical  entity,  which  appears  to  us  to  be  justifiable, 
at  least  provisionally,  in  view  of  the  following  considerations: 

(1)  This  condition  appears  at  an  age  when  dementia 
prsecox  is  already  rare — after  thirty  years  in  the  majority  of 
cases; 


DELUSIONAL  FORMS  249 

(2)  The  delusions  present  perfect  systematization  and  a 
regular  evolution,  which  is  unusual  in  dementia  prsecox; 

(3)  The  dementia  does  not  appear  for  many  years. 
Sometimes  it  does  not  appear  at  all,  even  when  the  patient 
has  reached  an  advanced  age  (Falret). 

The  name  "  dementia  prsecox  "  would  scarcely  be  ap- 
plicable to  an  affection  usually  appearing  at  an  adult  age, 
and  in  which  mental  deterioration  does  not  supervene  until 
long  after  the  onset — twenty  years  or  more.  Though  we  may 
consider  this  disorder  as  being  very  closely  related  to  de- 
mentia prsecox,  it  would  seem  that  more  facts  are  nec- 
essary to  estabUsh  the  identity  of  the  two  conditions. 

The  evolution  of  delire  chronique  occurs  in  four  periods, 
which  we  shall  consider  hastily,  for  the  symptoms  encoun- 
tered in  each  of  these  periods  have  already  been  described, 
and  it  is  but  the  special  grouping  of  these  s;yTnptoms  that 
imparts  to  this  disease  its  characteristic  aspect. 

First  Period:  I ncubation.— This  period  is  always  a  pro- 
longed one.  The  personaHty  of  the  patient  undergoes  a 
slow  and  insensible,  though  profound,  transformation.  The 
symptoms  observed  at  the  beginning  present  no  definite 
character.  They  consist  of  an  irritability  and  a  singular 
pessimism,  with  which  are  often  associated  hypochondriacal 
ideas. 

Little  by  Uttle  these  pathological  phenomena  become 
more  and  more  marked  and  develop  into  ideas  of  persecu- 
tion. Suspiciousness  and  uneasiness  appear  first,  followed 
later  by  delusional  interpretations:  the  patient  imagines  he 
is  watched  as  he  walks  in  the  street,  he  discovers  a  hidden 
meaning  in  a  conversation.  Illusions  of  all  the  senses,  but 
especially  those  of  hearing  and  of  smell,  gradually  appear 
as  the  affection  reaches  the  second  period. 

Second  Period:  Systematization  of  the  Delusions;  Appear- 
ance of  Hallucinations. — Hallucinations  are  constant  and 
affect  all  the  senses  except  vision.  They  are  always  of  a  pain- 
ful character.  The  first  to  appear  are  phonemes  (verbal 
auditors  hallucinations),   which,   vague  at  the  beginning, 


250  DEMENTIA  PR.ECOX 

assume  after  a  certain  time  remarkable  distinctness.  They 
are  followed  by  the  appearance  of  hallucinations  of  taste, 
smell,  general  sensibility,  including  the  genital  sense,  and, 
later  on,  motor  hallucinations  also. 

Visual  hallucinations  are  extremely  rare,  if  ever  present 
at  all.  On  the  other  hand,  illusions  of  sight  are  as  frequent 
as  those  of  the  other  senses,  often  taking  the  form  of  mistakes 
of  identity. 

By  degrees  the  delusions  group  themselves  and  become 
systematized.  The  hallucinations  are  interpreted  and  ex- 
plained. The  patient  recognizes  the  voices,  discovers  his 
persecutors,  the  methods  they  make  use  of,  and  the  aims 
they  pursue.  As  he  is  perfectly  convinced  of  the  reality 
of  his  delusions,  he  reacts,  seeking  to  protect  himself  against 
his  imaginary  enemies  and  to  find  justice.  The  means 
to  which  he  may  resort  are  infinitely  varied:  protests 
before  authorities  and  before  the  public,  frequent  changing 
of  residence,  and  but  too  often  assaults  and  murder. 

As  the  disease  advances,  more  and  more  evident  signs 
of  psychic  disaggregation  appear:  echo  of  the  thoughts, 
autochthonous  ideas,  motor  hallucinations,  etc. 

Third  Period:  Ideas  of  Grandeur. — Some  authors  regard 
the  ideas  of  grandeur  as  a  logical  sequence  of  those  of  per- 
secution, resulting  from  the  following  line  of  reasoning, 
which  the  patient  is  assumed  to  pursue  more  or  less  con- 
sciously: "  They  persecute  me  so  unmercifully  and  with 
such  stubbornness  because  they  are  afraid  of  me  or  jealous 
of  me."  This  explanation  is  perhaps  applicable  to  a  small 
number  of  cases,  but  not  to  all. 

The  real  cause  of  the  ideas  of  grandeur  is  the  mental 
deterioration  which  makes  its  appearance  at  this  period. 

These  ideas  are  of  all  possible  forms:  ideas  of  wealth, 
of  power,  or  of  transformation  of  the  personality.  One 
patient  was  God  and  his  persecutor  was  the  devil.  Another 
reigned  over  the  planet  Mars,  and  once  decided  to  destroy 
the  earth  by  means  of  aeroliths. 

Fourth   Period:     Dementia. — Mental   deterioration   here 


DIAGNOSIS  251 

becomes  clearly  apparent.  Its  character  is  very  similar  to, 
if  not  identical  with,  that  of  dementia  prsecox,  and  this 
is  undoubtedly  strong  evidence  of  a  close  relationship 
between  the  two  conditions. 

Almost  always  some  stereotyped  delusions  persist  as  a 
last  remnant  of  the  former  system  of  delusions. 

The  evolution  of  the  disease  is  very  slow,  often  requiring 
twenty  or  thirty  years  for  its  completion. 

The  'prognosis  is  fatal  from  the  psychic  standpoint. 
But  the  morbid  process  does  not  affect  the  organic  functions, 
and  the  patients  may  live  to  an  old  age. 

DIAGNOSIS,    PROGNOSIS,    ETIOLOGY,    NATURE    AND   TREATMENT 
OF   DEMENTIA   PRECOX 

Diagnosis. — This  is  based  on: 

(a)  Early  appearance  of  disorders  of  affectivity  and  of 
the  reactions; 

(6)  Delayed  appearance  of  intellectual  disorders  proper 
and  their  less  marked  intensity; 

(c)  The  contrast  existing  in  most  cases  between  the 
delusions  and  the  emotional  tone; 

{d)  The  purely  automatic  character  of  the  excitement  and 
of  most  of  the  reactions. 

It  is  at  the  beginning  that  the  greatest  difficulty  in 
diagnosis  is  experienced. 

Mental  confusion  is  to  be  distinguished  by  the  much 
more  pronounced  disorientation,  the  much  more  real  disorder, 
so  to  speak,  of  consciousness,  and  by  the  symptoms  of 
profound  denutrition,  sometimes  of  true  cachexia,  which  are 
a  constant  manifestation  of  the  disease. 

General  paralysis  is  distinguished  by  the  intellectual 
deterioration  en  masse,  by  its  characteristic  physical  signs, 
and  by  its  special  etiology. 

Delirium  tremens,  which  may  be  simulated  by  the  dehrious 
outbreaks  marking  the  onset  of  dementia  prsecox,  is  recog- 
nized by  the  pathognomonic  character  of  the  hallucinationSv 


252  DEMENTIA  PRECOX 

by  the  very  pronounced  allopsychic  disorientation  contrast- 
ing with  the  intact  autopsychic  orientation,  and  by  the 
history  and  physical  signs  of  alcoholism. 

Alcoholic  hallucinosis  is  often  very  difficult  to  dis- 
tinguish from  the  delusional  form  of  dementia  praecox. 
Special  attention  must  be  paid  to  the  etiology  of  the  case 
and  to  the  evolution  of  the  disease,  which  is  more  favorable 
in  alcohoHc  hallucinosis.  One  should,  however,  be  very 
guarded  in  rendering  a  diagnosis  as  well  as  a  prognosis.  In 
practice  it  is  not  rare  to  meet  with  chronic  alcoholics  who 
present  after  an  attack  of  alcoholic  hallucinosis  or  even  of 
dehrium  tremens  the  symptoms  of  dementia  praecox  which 
subsequently  run  the  classical  course  and  to  which  the  alco- 
holism has  served  merely  as  a  portal  of  entry. 

Prognosis. — This  is  always  grave  as  the  usual  outcome 
is  dementia. 

The  mental  deterioration  is  sometimes  so  slight,  it  is 
true,  that  it  appears  only  as  a  scarcely  perceptible  sluggish- 
ness of  association  of  ideas,  a  certain  degree  of  emotional 
indifference,  and  a  tendency  to  intellectual  fatigue. 

A  certain  number  of  patients  even  form  an  exception  to 
the  general  rule  and  recover  completely.  Such  cases  are  rare 
and  are  to  be  accepted  only  with  extreme  circumspection. 
Many  of  the  apparently  complete  recoveries  are  but  relative, 
and  many  recoveries  considered  permanent  are  but  tempo- 
rary ;  that  is  to  say,  they  are  mere  remissions. 

Indeed,  remissions  are  frequent  in  dementia  praecox. 
Their  duration  varies  within  very  wide  limits,  from  a  few 
hours  to  several  years.  It  is  not  exceptional  for  a  precocious 
dement  to  come  out  of  his  first  attack  apparently  unscathed, 
resume  his  normal  life  for  five,  six,  or  more  years,  suffer  a 
recurrency,  and  end  with  dementia. 

Dementia  praecox  is  not  in  itself  a  fatal  disease.  It 
may  terminate  fatally  from  some  of  its  complications.  The 
most  formidable  of  these  is  pulmonary  tuberculosis,  which 
is  apt  to  attack  patients  in  a  state  of  depression  or  in 
catatonic  stupor. 


PROGNOSIS  253 

Such  is  the  general  prognosis  of  dementia  praecox.  But 
since  the  possibihty  of  recovery  or  at  least  of  long  remissions 
exists  in  some  cases,  the  practical  psychiatrist  is  in  every 
case,  considered  individually,  confronted  with  the  problem 
of  rendering  not  a  general  but  a  special  prognosis. 

It  is  difficult,  not  to  say  impossible,  to  predict  the  course 
and  outcome  of  a  given  case.  Some  features  of  the  disease 
have,  however,  been  found  empirically  to  be  of  special  prog- 
nostic significance,  and  may  therefore  aid  the  physician  in 
forming  an  opinion. 

The  first  point,  one  that  should  never  be  lost  sight  of, 
is  that  only  those  cases  can  be  properly  regarded  as  absolutely 
incurable  in  which  there  is  actual  mental  deterioration. 
In  this  connection  the  most  certain  and  most  constant  sign 
of  mental  deterioration  is  indifference,  when  it  exists  inde- 
pendently of  any  marked  disorder  of  consciousness,  halluci- 
nations, excitement,  or  stupor,  in  other  words,  when  it 
exists  as  a  basic  disorder.  A  host  of  symptoms,  descriptions 
of  which  have  already  been  given  and  which  need  not  here 
again  be  entered  upon  (weakening  of  attention,  inaction, 
etc.),  are  seen  in  more  or  less  close  association  with  indiffer- 
ence; it  must,  however,  be  insisted  on  that  their  significance 
is  subordinate  to  that  of  indifference. 

Aside  from  these  states  of  actual  deterioration  the 
prognosis  should  always  be  guarded.  Nevertheless  valuable 
indications  may  be  gained  from  a  study  of  the  combination 
of  symptoms  before  the  development  of  mental  deteriora- 
tion; for  the  various  forms  in  which  the  disease  appears  and, 
in  the  same  form,  the  predominance  of  one  or  another  symp- 
tom, afford  very  different  indications. 

There  is  but  httle  to  be  said  concerning  the  simple 
form:  consisting  essentially  of  mental  deterioration,  it  may 
be  regarded  as  incurable  from  the  beginning.  The  question 
may  arise  whether  the  deterioration  will  progress  or  will 
remain  stationary.  Unfortunately  there  is  no  sign  which 
might  aid  in  forming  a  judgment  on  this  point. 

The   catatonic   form   presents   the   greatest    chance    of 


254  DEMENTIA  PRiECOX 

cure.  Kraepelin  has  observed  in  20%  of  his  cases  remissions 
so  complete  and  so  lasting  as  to  resemble  cures.  Other 
psychiatrists  the  world  over  have  reported  similar  results. 
It  seems  clear,  therefore,  that  recovery  from  catatonia  is  a 
possible  thing. 

Catatonic  symptoms  are  not  all  of  the  same  gravity. 
In  a  general  way,  states  of  excitement  are  of  lesser  gravity 
than  states  of  stupor,  the  latter  not  being,  however,  always 
incurable.  Negativism,  morbid  suggestibility,  or  delusions 
do  not  imply  a  particularly  unfavorable  prognosis  and  are 
capable  of  retrogression  and  complete  disappearance.  On 
the  other  hand  stereotypy,  whether  of  speech,  movements,  or 
attitudes,  very  marked  incoherence,  sudden  violent  and 
unexplained  impulses,  not  having  their  origin  in  a  delusion  or 
a  hallucination,  have  an  unfavorable  significance  and  gen- 
erally indicate  chronicity,  without,  however,  enabling  us  to 
predict  the  degree  of  mental  deterioration  to  which  the 
disease  may  lead.  These  symptoms  would  justify  us  in 
saying  fairly  definitely  that  the  patient  will  not  get  well, 
but  not  that  the  disease  will  be  arrested  in  its  progress,  or 
that  it  will  advance;  this  point  should  always  be  reserved. 

The  delusional  forms  are  not  all  of  the  same  gravity, 
although  on  the  whole  the  prognosis  of  delusional  dementia 
prsecox  is  more  grave  than  that  of  catatonia.  Systematiza- 
tion  of  the  delusions  is  almost  always  a  sign  of  chronicity. 
We  say  chronicity,  but  not  tendency  toward  either  rapid  or 
profound  mental  deterioration;  for  there  are  types  of 
paranoid  dementia  with  active  and  well  systematized  delu- 
sions in  which  it  would  be  very  difficult  to  detect  any  trace 
of  mental  deterioration.  Such  cases  approach  those  which 
are  to-day  still  described  under  the  name  of  delire  chronique 
without  dementia  and  which  have  been  insisted  on  by  Falret 
and  his  pupils,  when  they  have  maintained,  contrary  to 
Magnan,  that  the  period  of  dementia  may  be  wanting  in 
that  condition.  Hence,  the  indication  of  systematized 
delusions  is:  chronicity  very  probable,  but  not  necessarily 
dementia. 


ETIOLOGY  255 

This  probability  becomes  even  greater  when  the  delu- 
sional system  becomes  impoverished,  begins  to  show  features 
of  incoherence  and  absurdity,  and  especially  when  the 
delusions  cease  to  be  accompanied  by  adequate  affective  state 
and  reactions.  The  latter  principle  is  but  a  corollary  of 
the  principle  enunciated  above,  namely,  that  indifference 
without  an  obvious  basis  is  a  symptom  of  incurability. 

As  signs  of  unfavorable  prognosis  in  paranoid  dementia 
should  be  mentioned,  further,  multipHcity  of  hallucina- 
tions (when  occurring  independently  of  mental  confusion), 
in  particular  psychomotor  hallucinations  and  those  of 
general  sensibihty,  also  transformation  of  the  personality. 

These  are,  briefly  sketched,  the  data  which  enable  us 
in  a  certain  measure  to  foresee  the  course  in  a  given  case  of 
dementia  prsecox.  One  must  not  be  misled  into  taking  the 
value  of  these  criteria  to  be  any  greater  than  that  of  pro- 
visional landmarks;  in  the  present  state  of  our  knowledge 
skill  in  prognosis  is  dependent  chiefly  upon  appreciation  of 
fine  shades,  w^hich  comes  only  with  long  experience  in  mental 
diseases. 

As  being  of  prognostic  significance  may  be  mentioned 
further  very  decided  "  shut-in  "  make-up  (see  p.  259)  and 
insidious  onset,  both  points  being  of  grave  import,  while 
abrupt  onset  in  a  subject  of  normal  mental  make-up  affords 
greater  hope  of  improvement  or  recovery. 

Etiology. — Statistics  show  that  dementia  prsecox  is  a 
disease  chiefly  of  young  life.  According  to  Kraepelin,  in 
60%  of  the  cases  it  begins  before  the  twenty-fifth  year. 
It  is  rare  after  the  age  of  thirty.  It  seems,  however,  dif- 
ficult to  state  at  what  age  it  entirely  ceases  to  occur.  Cer- 
tain psychoses  identical  with  it  in  symptoms  and  evolution 
are  met  with  at  advanced  ages. 

Heredity  is  to  be  regarded  as  the  essential  cause  of 
this  disorder.^ 

^  E.  Riidin.  Einige  Wege  und  Ziele  der  Familienforschung,  mit 
Riicksicht  auf  die  Psychiatrie.  Zeitsch.  f .  d.  gesamte  Neurol,  u.  Psychiar 
trie,  Nov.,  1911. — A.  J.  Rosanoff  and  F.  I.  Orr.     A  Study  of  Heredity 


256  DEMENTIA  PRECOX 

Severe  infections,  overwork,  grief,  and  traumatisms  are 
occasionally  found  in  the  history  of  dementia  prsecox. 
(For  a  discussion  of  contributing  causes  see  pp.  9-12.) 

The  nature  of  the  disease  has  so  far  escaped  us,  and  we 
must  be  content  for  the  present  with  hypotheses. 

According  to  some  authors  dementia  prsecox  results 
from  an  arrest  of  mental  development;  the  brain  ceases  to 
acquire  new  impressions,  being  exhausted  by  previous  efforts 
which  were  too  great  for  the  energy  which  it  originally 
possessed.  This  explanation,  assuming  it  to  be  correct, 
can  account  for  but  a  small  number  of  cases.  In  reality, 
in  most  of  the  patients  we  observe  not  a  stationary  condition, 
but  a  true  retrogression.  Facts  that  have  been  acquired 
partly  disappear,  or  at  least  cease  to  be  coordinated  so  as  to 
give  rise  to  generalized  ideas.  Moreover,  the  disorders  of 
affectivity  and  of  the  will  cannot  be  accounted  for  by 
simple  arrest  of  development. 

According  to  Kraepelin's  hypothesis  dementia  prsecox 
is  a  disease  of  autointoxication.  Many  of  the  physical  symp- 
toms described  above  resemble  the  phenomena  by  which 
intoxications  of  exogenous  or  of  endogenous  origin  are 
usually  manifested:  epileptiform  attacks,  disorders  of 
the  circulation  and  of  the  secretions,  and  alterations  of  the 
general  nutrition. 

Possibly  the  poison  is  the  consequence  of  a  disorder  of 
secretion  of  the  genital  organs.  The  frequent  appearance 
of  the  first  symptoms  at  the  age  of  puberty,  or  in  the  female 
at  the  time  of  her  first  childbirth,  and  the  occasional  develop- 
ment of  the  disease  in  interrupted  stages,  each  corresponding 
to  a  period  of  pregnancy,  are  arguments  in  favor  of  this 
hypothesis. 

A  suggestive  and  far-reaching  hypothesis  bearing  on 
the  pathogenesis  of  dementia  prsecox  has  been  advanced  by 
Adolf  Meyer. 

in  Insanity  in  the  Light  of  the  Mendelian  Theory.  Amer.  Journ.  of  In- 
sanity, Oct.,  1911. — Ph.  Jolly.  Die  Hereditat  der  Psychosen.  Arch, 
f.  Psychiatrie  u.  Nervenkrank.,  Vol.  52,  1913. 


PATHOGENESIS  257 

It  is  quite  true  that  in  some  cases  of  dementia  prsecox 
we  find  a  history  of  some  infection  or  traumatism  which  is 
perhaps  to  some  extent  responsible  for  the  mental  disorder. 
But  it  is  equally  true  that  in  the  great  majority  of  cases, 
as  far  as  we  know,  the  disorder  develops  without  any  such 
cause. 

From  Meyer's  point  of  view  such  a  clinical  picture 
as  that  of  dementia  prsecox  may  be  the  result  of  an  acquisition 
and  unchecked  development  of  vicious  mental  habits  or  of 
abnormal  "  types  of  reaction  "  which  ultimately  replace  by 
substitution  healthy  and  efficient  mental  reactions  such  as 
are  necessary  in  our  constant  acts  of  adjustment  to  our  usual 
environment  as  well  as  to  newly  arising  situations. 

The  importance  of  this  view  lies  in  its  bearing  on  thera- 
peutics and,  even  to  a  greater  extent,  on  prophylaxis. 

To  quote  from  the  original  paper:  ^ 

"  Every  individual  is  capable  of  reacting  to  a  very  great  variety 
of  situations  by  a  limited  number  of  reaction  types." 

"  The  full,  wholesome,  and  complete  reaction  in  any  emergency  or 
problem  of  activity  is  the  final  adjustment,  complete  or  incomplete, 
but  at  any  rate  clearly  planned  so  as  to  give  a  feeling  of  satisfaction 
and  completion.  At  other  times  there  results  merely  an  act  of  perplex- 
ity or  an  evasive  substitution.  Some  of  the  reactions  to  emergencies 
or  difficult  situations  are  mere  temporizing  attempts  to  tide  over  the 
difficulty,  based  on  the  hope  that  new  interests  crowd  out  what  would 
be  fruitless  worry  or  disappointment;  complete  or  incomplete  for- 
getting is  the  most  usual  remedy  of  the  results  of  failure,  and  just  as 
inattention  and  distraction  correct  a  tendency  to  overwork,  so  fault- 
finding with  others,  or  imaginative  thoughts,  or  praying,  or  other 
expedients,  are  relied  upon  to  help  over  a  disappointment,  and,  as  a 
rule,  successfully.  Other  responses  are  much  more  apt  to  become  harm- 
ful, dangerous,  uncontrollable — a  rattled  fumbling,  or  a  tantrum,  or  a 
hysterical  fit,  or  a  merely  partial  suppression,  an  undercurrent,  an 
imcorrected  false  lingering  attitude,  or  whatever  the  reaction  t3T)e  of 
the  individual  may  be.  What  is  first  a  remedy  of  difficult  situations 
can  become  a  miscarriage  of  the  remedial  work  of  life,  just  as  fever, 
from  being  an  agent  of  self-defence,  may  become  a  danger  and  more 
destructive  than  its  source.  In  the  cases  that  tend  to  go  to  deteriora- 
tion certain  types  of  reactions  occur  in  such  frequency  as  to  constitute 

1  Adolf  Meyer.  Fundamental  Conceptions  of  Deinentia  Prcecox. 
British  Med.  Jour.,  Sept.  29,  1906. 


258  DEMENTIA  PRECOX 

almost  pathognomonic  empirical  units.  I  would  mention  hypochon- 
driacal trends,  ideas  of  reference,  fault-finding  or  suspicions,  or  attempts 
to  get  over  things  with  empty  harping,  unaccountable  dream-like, 
frequently  nocturnal  episodes,  often  with  fear  and  hallucinations, 
and  leading  to  strange  conduct,  such  as  the  running  out  into  the  street 
in  nightdress,  etc.,  or  ideas  of  strange  possessions  with  hallucinatory- 
dissociations,  or  the  occurrence  of  fantastic  notions.  All  these  appear 
either  on  the  groxmd  of  a  neurasthenoid  development,  or  at  times  sud- 
denly, on  more  or  less  insufficient  provocation,  with  insufficient  excuse, 
but  often  enough  with  evidence  that  the  patient  was  habitually  dreamy, 
dependent  in  his  adjustment  to  the  situations  of  the  world  rather  on 
shirking  than  on  an  active  aggressive  management,  scattered  and 
distracted  either  in  all  the  spheres  of  habits  or  at  least  in  some  of  the 
essential  domains  of  adjustment  which  must  depend  more  or  less  on 
instinct  or  habit.  On  this  ground  reaction  types  which  also  occur 
in  milder  forms  of  inadequacy,  in  psychasthenia  and  hysteria  or  in 
religious  ecstasy,  etc.,  turn  up  on  more  inadequate  foundation  and  with 
destructive  rather  than  helpful  results.  We  thus  obtain  the  negativism 
no  longer  as  healthy  indifference  and  more  or  less  self-sparing  dodging, 
but  distinctly  as  an  uncontrollable,  unreasoning,  blocking  factor.  We 
obtain  stereotypies  not  merely  as  substitutive  reactions  and  autom- 
atisms on  suflScient  cause  such  as  everybody  wiU  have,  but,  as  it  were, 
as  a  reaction  of  dead  principle  in  a  rut  of  least  resistance.  We  see 
paranoic  developments  with  the  same  inadequacy  of  starting  point 
and  failure  in  systematization,  and  in  holding  together  the  shattered 
personality,  etc." 

"  Therapeutically,  this  way  of  going  at  the  cases  wiU  furnish  the 
best  possible  perspectives  for  action.  We  stand  here  at  the  begin- 
ning of  a  change  which  wiU  make  psychiatry  interesting  to  the  family 
physician  and  practitioner.  As  long  as  consumption  was  the  leading 
concept  of  the  dreaded  condition  of  tuberculosis,  its  recognition  very 
often  came  too  late  to  make  therapeutics  tell.  If  dementia  is  the  lead- 
ing concept  of  a  disorder,  its  recognition  is  the  declaration  of  bank- 
ruptcy. To-day  the  physician  thinks  in  terms  of  tuberculous  infection, 
in  terms  of  what  favours  its  development  or  suppression;  and  long 
before  '  consumption '  comes  to  one's  mind,  the  right  principle  of 
action  is  at  hand — the  change  of  habits  of  breathing  poor  air,  of  physical 
and  mental  ventilation,  etc.  In  the  same  way,  a  knowledge  of  the 
working  factors  in  dementia  prsecox  will  put  us  into  a  position  of  action, 
of  habit-training,  and  of  regulation  of  mental  and  physical  hygiene, 
as  long  as  the  possible  '  mental  consumption  '  is  merely  a  perspective 
and  not  an  accomplished  fact.  To  be  sure,  the  conditions  are  not  as 
simple  as  with  an  infectious  process.  The  balancing  of  mental  metab- 
olism and  its  influence  on  the  vegetative  mechanisms  can  miscarry  in 
many  ways.     The  general  principle  is  that  many  individuals  cannot 


PATHOGENESIS  259 

afford  to  count  on  unlimited  elasticity  in  the  habitual  use  of  certain 
habits  of  adjustment,  that  instincts  will  be  undermined  by  persistent 
misapplication,  and  the  delicate  balance  of  mental  adjustment  and  of 
its  material  substratum  must  largely  depend  on  a  maintenance  of 
sound  instinct  and  reaction  tjT^e." 

Meyer's  vdews  gain  additional  significance  in  the  light  of 
the  more  recent  contribution  of  August  Hoch/  who  finds  in 
a  large  percentage  of  his  cases  of  dementia  prsecox  (51-66%) 
e^'idences  of  a  pecuhar  mental  make-up  which  he  has 
termed  "  shut-in  personality."  This  make-up  he  defines 
as  follows:  "  Persons  who  do  not  have  a  natural  tendency 
to  be  open  and  to  get  into  contact  with  the  en\ii'onment, 
who  are  reticent,  seclusive,  who  cannot  adapt  themselves  to 
situations,  who  are  hard  to  influence,  often  sensitive  and 
stubborn,  but  the  latter  more  in  a  passive  than  an  active  way. 
They  show  httle  interest  in  what  goes  on,  often  do  not  par- 
ticipate in  the  pleasures,  cares,  and  pursuits  of  those  about 
them;  although  often  sensitive  they  do  not  let  others  know 
what  their  conflicts  are;  they  do  not  unburden  their  minds, 
are  shj^,  and  have  a  tendency  to  five  in  a  world  of  fancies. 
This  is  the  shut-in  personality."  And  he  adds  further: 
"  What  is,  after  all,  the  deterioration  in  dementia  prsecox 
if  not  the  expression  of  the  constitutional  tendencies  in 
their  extreme  form,  a  shutting  out  of  the  outside  world,  a 
deterioration  of  interests  in  the  en^-ironment,  a  hving  in  a 
world  apart?  "  For  purposes  of  control  Hoch  examined 
the  histories  of  his  cases  of  manic-depressive  psj^choses  and 
failed  to  find  plain  evidences  of  a  marked  shut-in  personaUty.^ 

From  a  biological  viewpoint  dementia  prsecox,  or  at  least 
its  underljdng  constitution,  may  be  regarded  as  a  trait  or  a 
complex  of  traits  somewhat  analogous  in  its  origin  and 
mode  of  transmission  by  herechty  to  such  traits  as  color  of 
ayes,  color  of  hair,  statm'e,  etc.,  and  possessing  medical  and 
sociological  interest  only  by  reason  of  the  disability  by  which 
it  manifests  itself. 

1  Constitutional  Factors  in  the  Dementia  Prcecox  Group.  Rev.  of 
Neiu-ol.  and  Psychiatry,  Aug.,  1910. 

2  Journ.  of  Xerv.  and  Alent.  Dis.,  Apr.,  1909. 


260  DEMENTIA  PRECOX 

No  discussion  of  the  nature  of  dementia  praecox  would 
be  complete  without  a  reference  to  the  existence  of  various 
transition  forms,  firstly,  between  it  and  the  normal  mental 
condition,  and,  secondly,  between  it  and  other  constitutional 
disorders,  particularly  arrests  of  development,  epilepsy, 
paranoia,  and  manic-depressive  psychoses.^  Perhaps  of 
similar  significance  are  the  familial  relationships  between 
dementia  prsecox  and  these  disorders.^ 

The  recognition  of  these  facts  led  Adolf  Meyer  over 
fifteen  years  ago  to  provide  in  the  official  classification  of 
the  New  York  state  hospitals  such  groups  as  "  allied  to 
dementia  praecox "  and  "  allied  to  manic-depressive  psy- 
choses." 3  Similar  considerations  led  Bleuler  later  to  widen 
the  original  Kraepelinian  conception  of  dementia  praecox 
by  including,  under  the  new  name  schizophrenia,  various 
paranoic  conditions,  most  psychoses  arising  on  a  basis  of 
constitutional  psychopathic  inferiority,  many  somewhat 
impure  psychoses  usually  assigned  by  others  to  the  manic- 
depressive  group,  alcoholic  delusional  states,  and  other 
conditions  which  are  for  the  most  part  so  mild  as  to  be 
rarely  seen  in  institutions.'* 

Pathological  Anatomy. — Until  recently  most  psychiatrists 
placed    dementia   praecox   among   the    so-called   functional 

1  G.  H.  Kirby.  Catatonic  Syndrome  and  Its  Relation  to  Manic- 
Depressive  Insanity.  Journ.  of  Nerv.  and  Mental  Diseases,  Nov.,  1913. 
— T.  W.  Simon.  The  Occurrence  of  Convulsions  in  Dementia  Prcecox, 
Manic-Depressive  Insanity  and  the  Allied  Groups.  N.  Y.  State  Hosp. 
Bulletin,  Nov.,  1914. 

2  Berze.  Die  hereditdren  Beziehungen  der  Dementia  Prcecox. — A.  J. 
Rosanoff.  Dissimilar  Heredity  in  Mental  Disease.  Amer.  Journ.  of 
Insanity,  July,  1913.— A.  S.  Moore.  Some  Preliminary  Observations 
Concerning  the  Types  of  Psychoses  Occurring  in  the  Individual  Members 
of  Families.  N.  Y.  State  Hosp.  Bulletin,  May,  1913. — A.  Meyerson. 
Psychiatric  Family  Studies.  Amer.  Journ.  of  Insanity,  Jan.,  1917, 
and  April,  1918. 

^  Adolf  Meyer.  Seventeenth  Annual  Report,  N.  Y.  State  Com- 
mission in  Lunacy,  1904-190.5. 

*  E.  Bleuler.  Dementia  pracox  oder  Gruppe  der  Schizophrenien. 
Aschaffenburg's  Handbuch  der  Psychiatrie,  Vol.  IV.  Leipsic  and 
Vienna,  1911. 


TREATMENT  261 

disorders.  The  newer  studies  have,  however,  revealed 
fairly  constant,  though  not  pathognomonic,  anatomical 
changes.  Alzheimer  and  others  working  by  his  methods  have 
found  products  of  nerve  cell  degeneration  within  nerve  cells, 
in  the  clear  spaces  around  them,  and  especially  in  the 
perivascular  spaces.^  Southard,  having  selected  37  cases 
of  dementia  prsecox  showing  at  autopsy  no  coarse  compli- 
cating features  like  brain  atrophy,  intracranial  arteriosclero- 
sis, etc.,  has  found  in  19  foci  of  gliosis  distinctly  palpable  in 
the  fresh  brains.-  Rosanoff,  making  use  of  an  improved 
method  for  measuring  brain  atrophy,  consisting  essentially 
in  observing  the  relationship  between  cranial  capacity 
and  brain  weight,  has  found  very  close  and  constant  correla- 
tion between  the  degree  of  mental  deterioration  observed 
clinically  and  that  of  atrophy  found  at  autopsy  in  cases  of 
dementia  prsecox;  from  this  he  has  drawn  the  conclusion 
that  "  dementia  prsecox  is  associated  in  some  way  with 
changes  in  the  brain  which  lead  to  atrophy."  ^ 

Treatment. — Excitement,  refusal  of  food,  dangerous 
tendencies  are  treated,  as  they  arise,  by  the  methods  already 
described  in  the  first  part  of  this  book.  An  effort  should 
be  made  to  combat  stereotypy  in  all  its  forms  by  suggestion 
and  by  diversion  and  occupation.  Employment  at  useful 
labor  is  desirable  also  from  the  economic  standpoint;  pre- 
cocious dements  constitute  a  large  proportion  of  institution 
workers  and  thus  contribute  toward  their  support. 

1  Alzheimer.  Beitrage  zur  Kenntniss  der  pathologischen  Neuroglia 
und  ihrer  Beziehungen  zu  den  Abbauvorgdngen  in  nervosen  Gewebe. 
Histologische  und  histopathologische  Arbeiten  tiber  die  Grosshirnrinde, 
3,  1910. — Sioli.  Histologische  Befunde  bei  Dementia  Prcecox.  Allg. 
Zeitschr.  f.  Psychiatrie,  Vol.  XLVI,  p.  195,  1909.— Orton.  A  Study 
of  the  Braiyi  in  a  Case  of  Catatonic  Hirntod.  Amer.  Journ.  of  Insanity, 
Apr.,  1.913. 

-  Southard.  A  Study  of  the  Dementia  Prcecox  Group  in  the  Light 
of  Certain  Cases  Showing  Anomalies  or  Scleroses  in  Particular  Brain 
Regions.     Amer.  Journ.  of  Insanity,  July,  1910. 

^  Rosanoff.  A  Study  of  Brain  Atrophy  in  Relation  to  Insanity. 
Amer.  Journ.  of  Insanity,  July,  1914. 


CHAPTER  V 
PARANOIA  1 

Paranoia  is  to  be  looked  upon  as  the  development  of 
a  morbid  germ  the  existence  of  which  manifests  itself  in 
early  life  by  anomalies  of  character.  These  anomahes  may 
be,  to  use  the  apt  expression  of  Seglas,  "  summarized  in  two 
words:  conceit  and  suspicion."  At  a  certain  time  the 
pathological  tendencies  of  the  subject  find  their  expression 
in  a  fixed  idea,  and  the  delusional  state  is  established. 

Onset. — Sometimes  it  is  slow  and  gradual,  much  more 
frequently  rapid,  almost  sudden. 

In  the  first  case  the  dominant  traits  of  the  personality 
become  accentuated  httle  by  little.  The  patient  grows 
more  and  more  suspicious  and  vain  and  believes  himself 
to  be  the  object  of  malevolent  or,  on  the  contrary,  admiring 
reflections.  Delusional  interpretations  become  more  and 
more  numerous  until  finally  the  fixed  idea  appears,  an  idea 
of  persecution  or  of  grandeur,  around  which  a  whole  delu- 
sional system  is  subsequently  built  up. 

In  the  second  case  the  fixed  idea  is  primary  in  relation 
to  the  delusional  interpretations.  Sometimes  the  fixed 
idea  appears  in  childhood,  as  in  a  case  of  Magnan's:  the 
boy  when  questioned  concerning  his  vocation  replied  that 
he  was  going  to  become  a  pope.  Sander  has  described 
this  form  under  the  name  paranoia  originaire. 

Usually  the  fixed  idea  appears  at  a  later  period,  in 
youth  or  in  adult  age.     Often  it  is  based  upon  some  real 

1  Leroy.  Les  'persecutes  persecuteurs.  These  de  Paris,  1896. — 
Ballet  et  Roubinowitch.  Les  persecutes  persecuteurs. — Magnan,  Legons 
cliniques. 

262 


FUNDAMENTAL  FEATURES  263 

fact  the  significance  of  which  the  patient  misinterprets  or  the 
importance  of  which  he  exaggerates:  perfectly  justifiable 
disciplinary  measures  to  which  he  is  subjected,  loss  of 
money,  or  sometimes,  indeed,  a  true  injustice,  against  which, 
however,  nothing  can  be  done,  may  determine  the  onset  of 
the  disease.  Often,  also,  it  has  for  its  basis  the  extreme  credu- 
lity of  the  patient,  who  takes  in  earnest  a  simple  pleasantry 
or  some  idle  remark.  "  He  resembles  Napoleon,"  was  once 
remarked  by  someone  in  the  presence  of  a  psychopath. 
Immediately  the  latter  conceived  the  idea  that  he  belonged 
to  the  royal  family  and  that  he  was  "  the  Master  of  France," 
and  this  formed  the  starting  point  of  his  system  of  delusions. 
Fundamental  Features  of  the  Disease. — As  soon  as  the 
theme,  that  is  to  say  the  fixed  idea,  is  formed,  the  disease 
develops  very  rapidly  and  is  characterized  by: 

(1)  The  immutability  of  the  basic  fixed  idea; 

(2)  The  absolute  faith  which  the  patient  has  in  hi? 
delusions; 

(3)  The  apparent  logic  cf  the  delusional  system; 

(4)  The  promptness  and  intensity  of  the  reactions; 

(5)  The  absence  or  at  least  extreme  rarity  of  halluci- 
nations and  the  presence  of  numerous  false  interpretations; 

(6)  The  absence  of  mental  deterioration,  regardless  of 
the  length  of  time  that  the  disease  has  lasted. 

The  following  brief  abstract  from  the  history  of  a  case 
illustrates  these  characteristics  in  a  somewhat  schematic 
fashion: 

A  schoolmaster,  who  was  a  man  of  average  intelligence,  but  sus- 
picious and  conceited,  failed  to  receive  a  promotion  which  he  beUeved 
he  had  a  right  to  expect.  The  idea  that  he  was  the  victim  of  a  grave 
injustice  arose  in  his  mind  and  never  left  it  {immutability  of  the  fixed 
idea).  The  reasonings  of  his  friends  and  relatives  could  not  alter  his 
conviction  and  failed  to  dissuade  him  from  addressing  a  letter  of 
strong  protestation  to  the  school  director  {absolute  faith  in  his  delusions, 
promptness  and  intensity  of  the  reactions).  This  producing  no  effect 
other  than  the  loss  of  his  position,  he  applied  to  the  minister  of  public 
instruction,  to  the  president  of  the  republic,  to  the  tribunals.  He 
found  no  justice,  but  nevertheless  retained  confidence  in  the  excellence 


264  '    PARANOIA 

of  his  cause,  attributing  his  successive  disappointments  to  dishonesty 
of  the  representatives  of  authority  and  justice,  who  he  claimed  were 
in  league  against  him  because  his  high  intellect  overshadowed  them. 
Everything  now  became  clear  to  him;  he  understood  the  distrust 
shown  towards  him  and  the  attention  which  he  attracted  wherever 
he  went  {apparent  logic  of  the  delusions,  false  interpretations) .  Finally 
committed,  he  continued  to  protest  against  his  persecutors,  among  whom 
were  included,  as  might  be  expected,  the  physician  who  treated  him 
and  the  police  officer  who  arrested  him;  the  memory  still  remains 
perfect  and  the  mind  lucid,  although  the  disease  has  now  lasted  over 
twenty-five  years  {absence  of  mental  deterioration). 

It  is  often  stated  that  the  delusions  of  paranoiacs  are, 
in  a  manner,  logical;  that  is  to  say,  when  the  fixed  idea  once 
appears,  the  secondary  delusional  conceptions  are  the 
natural  outcome.  Thus  presented,  this  statement  is  not 
correct.  In  fact,  if  these  patients  possessed  a  faultless  logic 
it  would  render  apparent  to  them  the  inconsistency  of  their 
fixed  idea,  which  would  be  immediately  abolished.  It  is 
quite  true  that  these  patients  are  very  apt  to  use  and  abuse 
deductions  and  syllogisms,  which  trait  has  gained  for  them 
the  name  of  the  reasoning  insane.  But  their  logic  is  only 
apparent;  their  reasoning  is  always  tainted  with  the  same 
original  vice  that  leads  them  to  the  systematic  rejection  of 
arguments  opposing  their  ideas,  and  the  ready  acceptance  of 
hypotheses  which  arise  in  their  minds  as  a  result  of  their 
pathological  preoccupations.  Hence  their  delusional  inter- 
pretations, which  become  more  numerous  each  day  and  upon 
which  they  base  their  arguments,  and  the  childish  character 
of  the  proofs  which  they  accumulate.  A  vague  word  or  an 
evasive  reply  often  suffices  to  convince  them  that  their 
point  of  view  has  been  adopted  and  that  their  cause  has  been 
accepted.  The  concessions  occasionally  made  by  those 
against  whom  their  delusions  are  directed,  become,  in  their 
eyes,  ample  proof  that  these  people  admit  their  guilt;  thus 
misinterpreted  chance  occurrences  serve  to  feed  the  system 
of  delusions. 

Quite  frequently  their  reasoning,  subtle  and  plausible, 
though  radically  false,  is  imposed  upon  suggestible  individuals 


FORMS— DIAGNOSIS  265 

or  upon  those  of  shallow  minds.  Thus  they  often  have 
defenders  who  show  more  zeal  than  intelligence. 

Forms. — "  According  to  their  special  morbid  tendencies 
paranoiacs  may  be  classed  in  different  groups:  the  litigious 
paranoiacs  (paranoia  querulens  of  the  Germans),  who  prose- 
cute then'  imaginary  rights  in  the  courts;  the  hypochondri- 
acal paranoiacs,  who,  believing  themselves  to  have  been 
once  improperly  treated  by  a  physician,  bear  a  grudge  against 
all  physicians  whom  they  may  meet  in  the  course  of  their 
treatment,  and  annoy  them  in  various  ways;  the  filial  para- 
noiacs, who  beheve  that  they  have  found  their  father  in  some 
stranger^  whom  they  constantly  annoy  with  their  expressions 
of  tenderness  and  with  their  claims.  Another  group  is  formed 
by  the  amorous  paranoiacs:  Teulat,  the  lover  of  Princess 
de  B ,  was  a  splendid  example  of  this  type."  (Magnan.) 

To  the  preceding  groups  should  be  added  the  jealous 
paranoiacs,  in  whom  the  delusions  assume  the  form  of 
morbid  jealousy;  inventors  who  are  indignant  for  the 
rejection  of  their  fantastic  inventions;  ^  mystics  and  founders 
of  religions  who  often  succeed  in  gathering  under  their 
banners  an  imposing  train  of  feeble-minded,  or  at  least  un- 
balanced, indi\ddual3,  etc. 

The  hst  might  be  extended  indefinitely;  it  is  useless, 
however,  for  whatever  be  the  nature  of  the  fixed  idea,  the 
clinical  characteristics  of  the  delusional  state  do  not 
vary. 

Diagnosis. — The  first  question  that  may  arise  in  the 
mind  of  the  physician  is,  Are  the  ideas  of  the  subject  delu- 
sional or  not?  It  is  not  always  easy  to  answer  this  question. 
Delusions  sometimes  appear  very  plausible,  while,  on  the 
other  hand,  well-based  claims  may  resemble  the  delusions  of 
paranoia  on  account  of  the  obstinacy  with  which  they  are 
urged.  Only  by  a  very  careful  investigation  of  each  case 
can  errors  be  avoided. 

The   diagnosis  is  to   be  based  upon  the  fundamental 

1  Delarras.  Contribittion  a  V etude  du  delire  des  inventeurs.  These 
de  Bordeaux,  1900. 


266  PARANOIA 

characters  enumerated  above;  all  these  characters  in  com- 
bination are  not  observed  in  any  other  psychosis. 

In  favor  of  paranoid  dementia  are  mental  deterioration 
and  the  more  mobile  character  of  the  delusions.  In  delire 
chronique  there  are  the  constant  presence  of  hallucinations 
and  a  progressive  evolution  of  the  disease.  In  alcoholic 
delusion  of  jealousy  we  find  less  perfect  systematization, 
presence  of  hallucinations,  history  and  physical  signs  of 
alcoholism,  and  tendency  toward  recovery. 

Prognosis  and  Treatment. — Paranoia  is  a  chronic,  incur- 
able affection  which,  as  we  have  seen,  entails  no  mental 
deterioration. 

The  violence  of  the  reactions  sometimes  renders  com- 
mitment necessary.  There  are  no  known  means  for  com- 
bating the  delusions.  Psychic  treatment  has  no  influence 
whatever. 


CHAPTER  VI 

MANIC-DEPRESSIVE  PSYCHOSES  ^ 

Manic-depressive  psychoses  are  manifested  in  attacks 
presenting  a  double  characteristic:  a  tendency  toward 
recovery  without  mental  deterioration  and  a  tendency 
toward  recurrenc3^  From  a  symptomatic  standpoint  the 
attacks  are  of  three  types,  which  we  shall  describe  success- 
ively: 

Manic  type; 

Depressed  type; 

Mixed  types. 

§  1.     Manic  Type 

Mania  presents  itself  in  three  principal  forms:  simple 
mania,  delusional  mania,  and  confused  mania.  We  shall 
first  study  simple  mania,  which,  more  clearly  than  the 
other  forms,  exhibits  the  following  four  fundamental  symp- 
toms of  the  disease : 

Fhght  of  ideas; 

Morbid  euphoria  and  irritability; 

Impulsive  character  of  the  reactions; 

Motor  excitement. 

Simple  Mania. — Prodromata. — The  phenomena  of  manic 
excitement  are  almost  constantly  preceded  by  a  period  of 
depression  characterized  by  diminution  of  psychic  activity, 
which  sometimes  amounts  to  a  veritable  melancholic  state. 
Later  on  we  shall  see  the  importance  of  this  prodromal  period 
as  an  argument  for  the  unity  of  manic-depressive  psychoses. 

1  Kraepelin.  Lehrbuch  der  Psychiatrie,  Vol.  II. — Weygandt.  Ueber 
das  manisch-depressives  Irresein.  Berlin,  klin.  Woch.,  1901,  Nos.  4 
and  5. 

267 


268  MANIC-DEPRESSIVE  PSYCHOSES 

External  Aspect. — The  face  is  flushed,  the  eyes  brilliant, 
the  expression  happy  and  animated.  The  manner  and 
gestures  indicate  a  state  of  ease  contrasting  often  with  the 
usual  timidity  of  the  patient.  The  dress  is  showy,  ridiculous, 
and  ornamented  with  gaudy  trinkets;  the  clothes  are  in 
disorder,  perhaps  put  on  inside  out.  In  women  a  bodice 
excessively  decollete  and  the  skirt  raised  too  high  show  also 
the  erotic  tendencies. 

Intellectual  Disorders. — Lucidity  is  perfect,  orientation 
and  memory  are  intact. 

The  attention,  very  mobile,  is  distracted  by  all  external 
impressions. 

Associations  of  ideas,  uncontrolled,  are  formed  at  ran- 
dom from  similarities  of  sound,  superficial  resemblances, 
coexistences  in  time  and  space,  etc.  Flight  of  ideas  is  here 
encountered  in  its  typical  form. 

These  two  symptoms,  mobility  of  attention  (distract- 
ibility)  and  flight  of  ideas,  are,  as  we  have  already  seen,  an 
expression  of  weakening  of  normal  psychic  activity  and 
predominance  of  mental  automatism.  Under  these  condi- 
tions the  capacity  for  intellectual  labor  is  diminished. 

The  judgment,  which  is  largely  dependent  upon  asso- 
ciations of  ideas,  is  always  profoundly  disordered.  Though 
occasionally  the  patient  surprises  one  by  the  accuracy  of  his 
observation,  it  is  always  the  result  of  a  sort  of  automatic 
appreciation  bearing  upon  some  isolated  fact.  But  since 
judgment  necessitates  the  systematic  grouping  of  a  very 
considerable  number  of  ideas,  it  is  here  absent  or  at  least 
impaired.  A  maniac  who  notices  some  slight  defect  in  the 
dress  of  the  examiner  is  incapable  of  appreciating  the  im- 
portance of  an  event  or  of  an  act. 

Affective  Disorders. — These  consist  in  morbid  euphoria 
and  irritability. 

The  euphoria  is  often  very  marked.  Many  patients 
after  recovery  declare  that  they  had  never  felt  so  happy 
as  they  did  during  the  attack.  The  maniac  is  pleased 
with  everything,  and  the  contrast  is  particularly  striking 


MANIC  TYPE  269 

when  the  excitement  follows  a  period  of  depression  (attack 
of  double  form).  The  most  imperturbable  optimism  replaces 
the  pessimism  of  other  days.  Of  disease  insight  there  is  no 
question  at  all;  the  subject  "never  before  felt  so  well"; 
if  he  is  "  somewhat  nervous  "  the  fault  is  with  his  relatives, 
the  physicians,  or  the  nurses,  who  constantly  interfere  with 
him.  With  his  intelligence  and  activity  he  could  "  easily 
conduct  important  and  gigantic  enterprises."  If  he  were 
allowed  liberty  of  action,  he  would  show  everybody  what 
he  is  capable  of. 

Sad  impressions  are  dismissed  with  a  vague  remark 
or  a  joke.  A  maniac,  reminded  of  the  loss  of  his  property 
in  a  fire  (which  incidentally  was  the  cause  of  his  attack), 
replied  laugliingly:  "  IMoney  does  not  bring  happiness, 
and  besides  I  shall  have  earned  twice  as  much  six  months 
from  now." 

This  optimism,  however,  is  never  so  absurd  as  that 
of  general  paralytics  or  senile  dements.  Dumas  cites  the 
case  of  a  general  paralytic  who,  reminded  of  the  recent 
death  of  his  two  Uttle  daughters,  rephed:  "Well,  well! 
I  shall  resuscitate  them."  A  maniac  would  never  have  given 
such  an  answer. 

The  irritability  is  evident  in  the  violent  outbursts  of 
anger  which  occur  on  the  slightest  provocation.  The 
maniac  will  bear  no  contradiction  and  will  accept  no  sug- 
gestions. 

The  7noral  sense  is  always  diminished;  the  sense  of 
propriety  is  greatly  affected.  The  maniac  is  cjmical,  dis- 
honest, and  mischievous.  "  He  hes,  cheats,  and  steals  with- 
out the  least  scruple.  He  allows  himself  anything  that  in 
others  he  would  condemn  "  (Wernicke).  Quite  frequently 
he  will  tease  and  mock  others.  If  in  the  midst  of  his  ram- 
bling speech  some  pointed  or  amusing  remark  occurs,  it 
is  always  at  the  expense  of  others. 

Erotic  tendencies  fonn  an  integral  part  of  the  picture: 
the  patients  abandon  themselves  to  them  without  shame. 
Men   previously  exemplary  in  habits  go   around  with  pros- 


270  MA^IC-DEPRESSIVE  PSYCHOSES 

titutes.  Young  girls,  normally  very  reserved  in  their 
manner,  offer  themselves  to  everybody. 

One  frequently  sees  maniacs  indulging  in  alcoholic  excesses. 

The  patient  is  incapable  of  appreciating  the  significance 
of  his  acts  either  before  or  after  they  are  accompHshed. 
The  most  deprecable  acts  are  displayed  with  complacency 
and  become  the  objects  of  cynical  pleasantries;  compunction 
and  scruples  are  absent. 

Reactions. — The  elements  of  manic  excitement  consist  in: 
imperative  pressure  of  movement,  abnormal  rapidity  of 
reactions,  and  impulsive  character  of  the  acts. 

Manic  excitement  always  has  a  psychic  origin  (Wernicke) ; 
the  acts,  though  impulsive,  are  dependent  upon  an  appre- 
ciable cause  and  have  a  definite  purpose. 

This  excitement  often  assumes  the  aspect  of  morbid 
activity  which,  lacking  in  logical  sequence,  remains  un- 
productive when  it  does  not  become  harmful.  The  maniac 
every  instant  leaves  one  task  to  begin  another,  or  undertakes 
tasks  for  which  he  possesses  neither  the  necessary  aptitude 
nor  the  qualifications.  A  farmer,  fifty  years  of  age  and 
scarcely  able  to  read  or  write,  wanted  to  undertake  the 
study  of  Hebrew  "  to  unite  the  Jews  and  the  Protestants." 

The  maniac  is  strongly  inclined  to  intrude  into  the 
affairs  of  others,  causing,  as  might  be  expected,  much 
trouble.  He  offers  his  advice  and  assistance  to  every- 
body. In  the  hospital  he  accompanies  the  physician  on 
his  rounds,  makes  diagnoses,  and  prescribes  treatment. 
Often  he  tries  to  assist  the  nurses,  who  find  it  very  difficult 
to  moderate  his  zeal. 

In  the  more  marked  degrees  the  excitement  leads  the 
patient  to  many  eccentricities.  He  removes  his  clothing, 
replaces  it;  executes  pirouettes  and  dangerous  leaps;  sings 
obscene  songs;  performs  grimaces  and  contortions  for  the 
amusement  of  his  spectators;  and  frequently  annoys  others 
in  a  thousand  ways. 

The  conversation  is  animated,  strewn  with  eccentric 
expressions,  strange  words  and  puns.     The  language  may 


MANIC  TYPE  271 

be  either  profane  and  obscene  or  marked  by  a  labored  re- 
finement. The  tone  may  be  jocose  or  solemn,  accompanied 
by  the  gestures  of  a  gamin  or,  on  the  contrary,  by  those 
of  a  commander  or  a  preacher.  There  is  often  veritable 
logorrhcBa. 

The  writing  presents  analogous  characteristics.  Volu- 
bility and  prolixity  are  manifested  by  whole  pages  scribbled 
within  a  few  minutes.  The  lines  cross  each  other  in  every 
direction,  the  letters  are  large  in  size,  and  capitals  and  flour- 
ishes are  abundant.  Often  there  is  manic  graphorrhaea, 
analogous  to  the  manic  logorrhoea  referred  to  above. 

The  discourse  is  conducted  at  random:  reflections  upon 
questions  of  transcendental  philosophy  as  well  as  upon  those 
of  dress  or  cooking;  slander  and  intimate  confidences, 
extravagant  projects,  and  erotic  proposals.  The  maniac 
conceals  nothing. 

Physical  Symptoms. — ^We  find  in  mania  the  physical 
symptoms  which,  we  have  already  seen,  are  associated 
with  morbid  euphoria :  the  general  nutrition  and  the  periph- 
eral circulation  are  active,  the  pulse  is  full  and  rapid, 
respiration  is  deep  and  accelerated,  the  appetite  is  good,  and 
the  weight  increases. 

Sleep  is  diminished,  occasionally  altogether  absent; 
but  in  spite  of  the  insomnia  the  patient  experiences  no 
fatigue. 

Often  in  women  the  menses  are  suspended,  and  their 
return  indicates  the  approach  of  recovery.  When  they 
persist  through  the  attack  their  appearance  is  likely  to 
provoke  a  recrudescence  of  excitement. 

Delusional  Mania. — The  fundamental  symptoms  are 
the  same  as  those  of  simple  mania.  The  excitement  may  be 
more  marked  and  the  lucidity  perhaps  transitorily  disturbed. 

The  delusions  are  usually  mobile  and  consist  in  ideas 
of  grandeur. 

The  most  varied  delusions  follow  each  other,  modified 
every  instant  by  external  impressions.  The  patient  assumes 
all  the  titles  mentioned  to  him :  he  is  in  turn  pope,  physician, 


272  MANIC-DEPRESSIVE  PSYCHOSES 

and  admiral.  Occasionally  the  delusions  are  referred  to  the 
past  and  take  the  form  of  pseudo-reminiscences:  a  shoe- 
maker pretended  to  have  directed  an  expedition  to  the 
North  Pole. 

The  patient  often  transforms  the  surroundings  in  which 
he  finds  himself.  A  maniac  called  the  head  nurse  of  the 
ser\'ice  Vv^here  he  was  treated  the  chief  of  his  mihtary  station, 
and  the  physician  the  prince  of  Sagan. 

The  costume  corresponds  with  the  delusions :  the  patients 
clothe  themselves  in  fantastic  uniforms,  cover  their  chests 
with  decorations,  comb  their  hau'  in  the  style  of  Bonaparte, 
etc. 

Sometimes  one  delusion  persists  and  remains  fixed  during 
the  entire  duration  of  the  attack  in  the  midst  of  more  mobile 
accessory  delusions:  a  modest  business  agent  for  several 
months  proclaimed  himself  to  be  the  President  of  France, 
and  referred  to  the  physicians  and  nurses  as  his  "  grand 
staff." 

The  maniac  never  has  absolute  faith  in  his  delusions. 
His  conviction  is  easily  shaken.  Often  he  only  half 
believes  in  the  pompous  titles  that  he  gives  himself;  his 
delusions  are  a  sort  of  pleasantry  with  which  he  amuses 
himself  and  with  which  he  mystifies  those  about  him. 

Some  ideas  of  persecution,  mostly  bearing  upon  the 
deprivation  of  liberty,  may  occur  in  addition  to  the  ideas  of 
grandeur.  In  some  cases  even  hypochondriacal  ideas  may 
occur.  The  patient  declares  that  he  is  afflicted  with  a  grave 
disease,  but  that  he  will  cure  himself  "  by  taking  a  trip  to 
London  "  or  by  having  an  operation  done  by  "  the  greatest 
specialists  of  Paris  and  America." 

Hallucinations  are  rare  and  fleeting.  On  the  other  hand,' 
illusions  are  frequent  and  lasting;  they  often  assume  the 
form  of  mistakes  of  identity:  the  patient  is  apt  to  beheve 
himself  surrounded  by  his  acquaintances  and  by  famihar 
objects. 

In  grave  forms,  during  the  excited  paroxysms,  con- 
sciousness at  times  undergoes  a  certain  degree  of  clouding 


MANIC  TYPE  273 

and  the  period  of  illness  leaves  but  a  very  vague  impression, 
or  none  at  all,  upon  the  memory. 

The  following  case  is  a  good  example  of  delusional  mania. 

Gabrielle  L.,  fifty-two  years  old,  housewife.  Family  history 
unknown.  The  patient  has  always  been  impressionable  and  lively; 
inteUigence  normal.  She  had  five  previous  attacks  of  mania,  the 
first  at  the  age  of  nineteen;  all  terminated  in  recovery. 

The  present  attack  began  with  rambling  speech,  assaults  upon 
others,  and  tendency  to  alcoholic  excesses;  the  patient,  though  usually 
temperate,  began  to  driak  to  intoxication.  She  was  taken  to  the 
Clermont  Asylum,  where  Dr.  Boiteaux  issued  the  following  certificate 
of  lunacy:  "  Condition  of  acute  mania  with  extreme  disorder  of  idea- 
tion, speech,  and  conduct.  Illusions  of  the  senses.  Obscene  actions. 
Ideas  of  grandeur:  owns  millions,  heavens  and  earth.  Excited,  dif- 
ficult to  control." 

On  February  2.5,  1904,  one  month  after  the  patient's  admission 
to  the  asylum,  examination  was  as  follows:  Medium  stature,  strong 
constitution,  slight  obesity,  skin  flushed,  voice  loud,  gestures  hvely, 
clothing  disarranged,  hair  down  over  the  shoulders.  From  the  begin- 
ning the  patient  showed  extreme  familiarity.  She  offered  her  arm  to 
the  physician,  whom  she  took  to  be  the  husband  of  the  head  nurse, 
and  laughingly  asked  the  latter  if  she  was  not  jealous.  She  was  well 
oriented  as  to  place;  she  knew  that  she  was  in  the  Insane  Asylum  at 
Clermont  where  she  had  already  been  five  times  before.  Her  orienta- 
tion of  time  was  somewhat  inaccurate:  she  said  the  year  was  1904, 
that  it  was  the  spring  of  the  year,  and  gave  the  date  as  March  25 
(actual  date  February  25,  1904);  on  being  asked  to  think  a  while  and 
make  sure  of  the  date,  she  said:  "  Why,  of  course  it  is  March,  a  few 
days  ago  we  had  a  holiday,  that  was  Mid-Lent."  (She  was  evidently 
referring  to  Shrove  Tuesday.)  Later  other  ideas  appeared  and  it 
became  impossible  to  prevail  upon  the  patient  to  reflect  properly  before 
speaking.  She  had  a  certain  reaUzation  of  her  condition:  she  said 
she  felt  odd,  "  at  times  driven  to  play  all  sorts  of  silly  pranks."  She 
was  very  obedient,  and  always  started  out  with  remarkable  eagerness 
to  carry  out  any  order  that  might  be  given  her.  But  her  extremely 
mobile  attention  caused  her  to  be  each  instant  distracted  from  the 
object  to  be  attained.  She  was  asked  to  wTite  a  letter:  "  Why,  cer- 
tainly! To  whom?  "  To  whomever  you  wish.  "  Very  weU,  to  the 
President  of  the  Republic?  To  the  Minister  of  War?  No,  I  shaU  write 
to  my  husband."  Then  she  began  to  write:  To  Mr.  L.,  Gardener 
in  C.  .  .  .  Then  turning  again  to  the  physician:  "  Because,  you 
know,  we  have  been  living  in  C.  .  .  .  for  the  past  eighteen  years. 
I  have  a  house  there.     The  hospital  at  C.  .  .  .  belongs  to  me.     I 


274  MANIC-DEPRESSIVE  PSYCHOSES 

know  Sister  Antoinette  there.  They  wanted  me  to  disguise  myself 
as  a  Sister,  but  my  husband  wouldn't  have  it.  He  adores  me,  my 
husband  does!  "  She  was  again  asked  to  write,  which  she  did,  jab- 
bering all  the  time  and  reading  aloud  everything  she  wrote.  Every 
moment  her  attention  kept  being  distracted  by  the  conversation  of 
the  persons  in  the  room,  although  they  spoke  in  a  low  voice  and  upon 
matters  which  did  not  concern  the  patient.  They  spoke,  in  fact, 
about  another  patient  who  helped  the  nurses  with  the  service  in  the 
dining-room.  "  Good  gracious!  "  exclaimed  the  patient,  interrupting 
her  writing  and  bursting  out  with  laughter,  "  that  woman  is  pretty 
stingy  with  her  bread!  One  would  think  she  was  paying  for  it!  It  was 
I  that  gave  her  the  money  to  buy  it  with!  "  When  asked  again  to 
continue  her  letter  she  willingly  resumed  her  writing.  A  minute  later 
they  spoke  about  another  patient,  and  someone  made  the  remark, 
"She  does  not  sleep."  Tliis  started  the  patient  again:  "Who,  I? 
I  don't  sleep?  Why,  I  sleep  like  a  dormouse!  "  It  is  to  be  noted  that 
she  wrote  slowly,  seeking  for  words.  Having  had  but  httle  schooUng, 
writing  in  her  case  did  not  develop  into  an  automatic  function.  She 
threw  down  her  pen  after  having  written  a  few  disconnected  Lines.  She 
was  then  given  a  paper  and  asked  to  read  aloud  one  of  the  news  items. 
Her  attention  was  at  once  attracted  by  a  picture  below  the  news  item 
and  she  exclaimed,  pointing  to  it:  "Here  is  a  pretty  woman!  She 
resembles  Mrs.  P."  She  was  again  urged  to  read.  She  read  the 
first  line  with  difficulty,  owing  to  her  poor  vision,  and  continued  to 
read  on  the  same  level  in  the  next  column.  Again  the  above  news  item 
was  pointed  out  to  her.  It  was  about  some  poor  old  man.  The 
patient  at  once  stopped  her  reading.  "  This  is  a  jolly  story!  The 
poor  old  man!  and  the  veterans!  I  visited  them  once,  also  the  build- 
ings for  arts  and  for  commerce,"  With  a  good  deal  of  urging  she 
was  finally  induced  to  read  the  entire  news  item;  but  it  made  very 
little  impression  on  her  mind;  a  quarter  of  an  hour  later  she  was 
unable  to  tell  even  briefly  what  she  had  read,  declaring  simply 
that  it  was  something  about  an  old  man.  "  It  is  very  sad,"  she 
added,  "  sad  and  humiliating.  Thinking  of  death  always  distresses 
me,  but  I  am  very  fond  of  flowers.  My  husband  is  a  gardener  in 
C.  ...  He  buys  his  seeds  from  Vilmorin,  also  his  tobacco."  Numer- 
ous unsystematized  grandiose  delusions:  she  is  a  midwife,  she  studied 
for  forty  years;  she  is  a  millionairess,  owns  mansions;  her  husband 
has  invented  perpetual  motion,  made  the  model  with  nothing  but  his 
knife;  he  has  also  invented  a  method  for  making  cheese  boxes  out  of 
the  stalks  of  rye,  which  he  will  seU  for  ten  cents  apiece.  He  is  related 
to  the  king  of  Italy  and  is  of  noble  descent.  In  her  delusions  the 
patient  showed  marked  suggestibility:  she  was  asked,  "  Have  you  ever 
been  on  the  stage?" — "  Why,  yes,  I  played  in  The  Chimes  of  N ormandxj ." 
Here  she  began  to  sing:    "  Will  you  look  this  way,  will  you  look  that 


MANIC  TYPE  273 

way?  "  Her  children  are  also  actors.  She  played  with  them  at  the 
Castle  Theatre,  also  with  Sarah  Bernhardt.  Here  her  eye  fell  upon  the 
word  "  Minister  "  printed  in  large  letters  in  the  paper;  she  said:  "  My 
husband  has  not  yet  been  made  Minister,  but  with  his  ability  he  wiU 
not  have  to  wait  long."  She  has  no  hallucinations,  but  numerous 
illusions,  especially  those  of  vision.  She  thinks  she  knows  all  those 
about  her.  One  nurse  is  her  cousin,  another  is  her  neighbor  living 
across  the  street.  Her  motor  excitement  is  very  marked.  The  patient 
tries  to  do  every  kind  of  work;  she  makes  a  few  sweeps  with  the  broom, 
then  suddenly  rushes  to  assist  a  nurse  carrying  a  pad  of  water,  then 
leaves  the  nurse  with  her  paU  of  water  to  go  and  make  peace  between 
two  quarrehng  patients.  Without  any  intention  of  malice,  she  has 
frequent  altercations  with  other  patients  who  are  annoyed  by  her 
screams,  her  songs,  and  her  wUd  pranks.  She  picks  up  all  sorts  of 
objects  and  accumulates  them  in  her  clothes:  scraps  of  paper,  bits  of 
glass,  wood,  and  metal,  pieces  of  bread  and  cheese.  She  herself  laughs 
when  an  inventory  is  taken  of  aU  this  rubbish,  and  makes  no  objection 
to  its  being  taken  away  from  her. 

No  noteworthy  disorders  in  her  general  condition.  She  eats  at 
aU  times,  abundantly  and  gluttonously.  Sleep  somewhat  disturbed: 
she  passes  part  of  the  night  wandering  about  the  dormitory,  singing 
and  jabbering. 

Confused  Mania. — Clouding  of  consciousness  is  here 
permanent.  The  attack  begins  suddenly  or  after  a  short 
prodromal  period,  characterized  from  the  beginning  by- 
complete  disorientation,  very  great  excitement,  and  totally 
incoherent  delusions.  Numerous  hallucinations  always  ac- 
company the  delusions.  The  form  of  the  delusions  is  very 
variable:  in  confused  mania  are  often  encountered  ideas  of 
grandeur,  persecution,  and  occasionally,  by  way  of  an 
accidental  episode,  some  melancholy  delusions. 

Even  when  the  grandiose  ideas  predominate  euphoria 
is  very  frequently  absent.  The  cause  of  this  anomaly 
probably  exists  in  the  purely  automatic  character  of  all 
the  psychic  manifestations.  To  provoke  a  sense  of  pleasure 
activity  must  be  conscious,  that  is  to  say,  accompanied  by  a 
voluntary  effort,  no  matter  how  slight;  whereas  in  confused 
mania  fragmentation  of  the  personality  is  such  that  flight 
of  ideas  is  effected  with  extreme  facihty:  effort  is  absent 
and  with  it  the  euphoria. 


276  MANIC-DEPRESSIVE  PSYCHOSES 

The  patient  loses  weight,  the  features  become  drawn 
jut,  the  pulse  grows  small  and  depressible.  The  inten- 
sity of  the  excitement  permits  of  no  regular  alimentation. 

Filthy  tendencies  are  frequent:  unless  watched  con- 
stantly the  patient  is  apt  to  smear  the  walls,  his  bed,  his 
clothing,  and  his  body  with  fseces.     Some  will  even  eat  faeces. 

The  attack  may  terminate  in  death,  either  from  ex- 
haustion or  from  some  complication:  pneumonia,  suppura- 
tion occasioned  by  traumatism,  etc. 

General  Course,  Duration,  and  Prognosis  of  a  Manic 
Attack. — The  course  of  mania  is  capricious.  In  a  general 
way  it  may  be  represented  by  a  curve  which  at  first  ascends, 
then  remains  horizontal  for  some  length  of  time,  and  finally 
gradually  descends.  But  this  curve,  far  from  being  regular, 
is  interrupted  by  oscillations  indicating  either  sudden 
exacerbations  or  attenuations  of  the  symptoms,  or  even 
remissions  the  duration  of  which  may  vary  from  several 
minutes  to  several  days. 

The  progress  of  the  attack  may  also  be  interrupted 
by  phenomena  of  depression  which  are  sometimes  quite 
marked,  though  very  brief  in  duration.  As  we  shall  see 
later  on,  this  fact  contributes  to  the  proof  of  the  homogene- 
ity of  manic-depressive  phychoses. 

The  duration  of  the  attack,  whatever  its  form,  cannot 
be  predicted.  Some  attacks  terminate  in  a  few  hours, 
deserving  a  place  among  the  transitory  psychoses,  others 
continue  for  several  years. 

The  prognosis,  leaving  out  the  cases  in  which  life  is  en- 
dangered by  the  intensity  of  the  excitement  or  by  some 
complication,  is  favorable  as  to  termination  of  the  attack. 
Recovery  with  restitutio  ad  integrum  is  the  rule. 

In  some  cases  recovery  has  been  observed  to  occur  fol- 
lowing some  acute  somatic  disease. 

Treatment. — Rest  in  bed  in  these  cases  performs  miracles. 
It  is  well  accepted  and  easily  instituted.  Unfortunately  it 
is  not  possible  at  present  to  say  whether  or  not  it  actually 
shortens  the  duration  of  the  attack. 


DEPRESSED  TYPE  277 


§  2.     Depeessed  Type 

The  fundamental  sj-mptoms  of  the  depressed  type  are: 

Psychic  mhibition ; 

A  painful  emotional  state  associated  with  indifference; 

Abouha. 

As  in  the  case  of  mania,  we  distinguish  here  three  forms: 
simple,  delusional,  and  stuporous  depression. 

Simple  Depression. — Onset. — Usually  insidious,  pre- 
ceded by  ill-defined  prodromata,  such  as  general  tired  feel- 
ing, insomnia,  anorexia,  discouragement. 

The  external  aspect  of  the  patient  is  one  of  sadness, 
Ustlessness,  and  indifference.  The  features  are  drawn  out, 
head  bowed  down  upon  the  chest,  arms  hanging  inertly  at 
the  sides  or  resting  upon  the  knees.  The  general  bearing 
is  slouchy. 

Intellectual  Disorders. — The  psychic  inhihition  brings 
about  very  marked  weakening  of  attention  and  considerable 
sluggishness  of  the  association  of  ideas.  All  intellectual 
exertion,  such  as  narration  of  an  event  well  knoTVTi  to  the 
patient  or  a  small  calculation,  is  impossible  or  can  be  accom- 
plished only  after  repeated  and  painful  efforts.  Though 
lucidity  is  mtact,  perceptions  are  incomplete,  uncertain 
and  often  inaccurate.  Everything  appears  to  the  patient 
strange  or  unrecognizable:  persons,  objects,  and  even 
his  own  body.  Here  we  have  a  condition  bordering  upon  a 
delusional  state.  Another  step  and  we  have  illusions  and 
hypochondriacal  ideas. 

The  disorders  of  judgment  are  less  marked  than  in  mania. 
The  patient  is  quite  frequently  conscious  of  his  condition 
to  some  extent.  He  feels  that  he  is  changed,  ill,  and  it 
seems  to  him  that  his  mind  is  paralyzed. 

Affective  Disorders. — The  mood  is  sad,  gloomy,  pessi- 
mistic. The  patient  emits  monotonous  groans.  "VMiile 
the  maniac  brings  disorder  into  the  hospital,  the  melancho- 
liac  brings  depression  and  gloom. 


278  MANIC-DEPRESSIVE  PSYCHOSES 

Psychic  anaesthesia  is  usually  marked,  and  sometimes 
the  patient  is  conscious  of  it.  He  complains  of  having 
become  indifferent  toward  everything,  of  experiencing  no 
affection. 

Upon  this  general  state  of  depression  and  sadness  may 
be  engrafted  a  spell  of  anxiety,  usually  transient.  In  no 
case,  however,  is  the  psychic  pain  as  intense  as  in  involu- 
tional melancholia.  The  depressed  phases  of  manic-depres- 
sive psychoses  correspond  to  passive  depression. 

Disorders  of  the  Reactions. — These  all  result  from  the 
marked  abouha  present  in  such  cases,  which  is,  in  its  turn, 
a  manifestation  of  the  psychic  paralysis. 

The  execution  of  the  simplest  act  necessitates  an  effort 
so  great  at  times  that  the  patient  gives  up  the  attempt. 
Like  the  psychic  indifference,  this  sjnaaptom  may  be  a  con- 
scious one. 

Combined  with  insufficiency  of  perception,  aboulia 
brings  about  doubt.  The  patient  Hves  in  constant  indecision 
and  uncertainty. 

Conversation  with  the  patient  is  most  unsatisfactory. 
Often,  in  spite  of  all  persistence,  the  patient  remains  mute 
or  responds  by  an  unintelligible  murmur  or  whispering. 
The  mental  synthesis  necessary  for  an  elaboration  of  a 
response  is  impossible  for  him.  In  the  milder  cases,  to  some 
very  simple  questions  repeated  several  times  brief  answers 
are  obtained. 

The  voice  is  scarcely  audible,  the  speech  is  indistinct. 
The  same  words  are  constantly  reiterated,  expressing 
doubt,  indecision,  sadness:  "What  is  this?  .  .  .  What  is 
going  to  happen?  .  .  .  This  is  frightful." 

The  writing  is  slow;  letters  are  poorly  formed,  small, 
disconnected. 

Physical  Symptoms. — These  have  already  been  described 
in  connection  with  morbid  depression.  We  shall  review  them 
briefly. 

The  peripheral  circulation  is  sluggish,  the  extremities 
cold   and   cyanotic.     The  pulse  is  small,   of  low  tension. 


DEPRESSED  TYPE  279 

sometimes    slowed.     The   heart  sounds    are   muffled.     The 
temperature  may  be  subnormal. 

The  coated  tongue,  fetid  breath,  a  sense  of  weight  in 
the  stomach,  constipation,  and  anorexia  reveal  a  yoor  state 
of  the  digestive  functions. 

Loss  of  weight  is  a  constant  phenomenon.  The  return 
to  the  normal  weight  always  indicates  the  end  of  the  attack. 

Sleep  is  diminished,  unrefreshing,  disturbed  by  night- 
mares. 

Often  the  patient  complains  of  headache  and  of  vague 
pains  in  the  limbs. 

Cutaneous  sensibility  is  blunted. 

The  tendon  reflexes  are  often  diminished. 

Delusional  Depression. — Always  secondary  to  the  emo- 
tional state,  the  delusions  are  preceded  by  a  longer  or  shorter 
period  of  simple  depression. 

They  present  the  usual  characters  of  depressive  ideas 
and  assume  the  most  varied  forms:  hypochondriacal  ideas, 
ideas  of  humihty,  of  self-accusation,  or  of  ruin,  fear  of  ter- 
rible punishment. 

As  in  involutional  melancholia,  the  morbid  idea  may 
occur  at  first  in  the  shape  of  an  imperative  idea.  The  mind 
realizes  it  is  false  and  tries  to  reject  it.  After  a  more  or  less 
prolonged  struggle,  the  mind  yields:  the  imperative  idea 
becomes  a  fixed  idea,  and  a  delusional  state  is  established. 

Occasionally  these  delusions  are  quite  absurd  and 
resemble  those  of  dementia  praecox.  In  other  cases  they  are 
associated  with  ideas  of  persecution  and  become  systema- 
tized to  a  certain  extent,  constituting  a  systematized  de- 
lusional state  of  self-accusation  or  of  persecution,  as  the  case 
may  be. 

Hallucinations  are  rare.  The  least  exceptional  are 
those  of  vision. 

Illusions,  though  less  numerous  than  in  mania,  are, 
however,  quite  frequent.  Following  the  general  rule, 
the  psycho-sensory  disorders  are  an  expression  of  the  de- 
lusional preoccupations. 


280  MANIC-DEPRESSIVE  PSYCHOSES 

Lucidity  may  be  transitorily  affected.  The  usual  inertia 
is  sometimes  effaced  and  replaced  by  a  certain  degree  of 
excitement.  In  other  cases  it  becomes,  on  the  contrary, 
more  marked,  giving  rise  to  transient  stupor. 

Depression  with  Stupor. — This  form  rarely  begins  as  such; 
it  is  usually  preceded  by  simple  or  delusional  depression. 

The  characteristic  trait  here  is  complete  inertia,  associated 
with  absolute  indifference  to  all  external  impressions.  The 
physiognomy  is  stupid,  sometimes  expressing  fear. 

The  usual  physical  symptoms  of  depression  are  here 
very  pronounced. 

Almost  always  the  patient  becomes  neghgent  and 
filthy,  wetting  and  soiling  his  bed. 

In  some  cases  may  be  observed  a  tendency  to  cata- 
leptoid  attitudes. 

The  stupor  may  have  one  of  two  different  origins: 

(1)  Psychic  inhibition  reaching  an  extreme  degree  of 
intensity  suppresses  all  conscious  and  voluntary  intellectual 
activity.  The  indifference  is  complete,  the  psychic  pain,  on 
the  contrary,  becoming  nil;  in  fact  inhibition  is  never  per- 
ceived as  a  painful  phenomenon  unless  the  mind  seeks  to 
overcome  it;  in  stupor  the  arrest  of  psychic  activity 
is  so  complete  that  the  patient  makes  no  attempt  to 
react. 

(2)  The  patient's  mind  is  preoccupied  by  intense,  fright- 
ful delusions.  There  is  an  endless  succession  of  terrifjdng 
hallucinations  analogous  to  those  of  epileptic  delirium. 
The  patient  is  in  a  frightful  nightmare  which  completely 
absorbs  him,  rendering  him  insensible  to  impressions  of  the 
external  world. 

Course,  Duration,  and  Prognosis  of  the  Depressed  Type 
of  Manic-Depressive  Psychoses. — As  in  mania,  the  course 
is  irregular,  interrupted  by  temporary  remissions  and 
exacerbations.  The  duration  varies  within  very  wide 
limits,  from  a  few  days  to  several  months  or  even  years; 
the  prognosis  is  always  favorable  for  recovery  from  the 
attack,  except  in  cases  with  grave  somatic  comphcations. 


MIXED  TYPES  281 

Physical  improvement,  especially  increase  in  weight,  usually 
indicates  the  approach  of  recovery. 
The  treatment  consists  in: 

(1)  Sustaining  the  strength  of  the  patient  by  rest, 
especially  rest  in  bed,  and  by  a  plentiful  and  nutritious 
diet; 

(2)  Careful  watching  to  prevent  suicide; 

(3)  Calming  agitation,  when  present,  by  the  usual 
procedures; 

(4)  Combating  the  gastric  disorders  and  the  phenomena 
of  autointoxication  that  are  so  frequent  in  states  of  depression. 

Psychic  treatment  in  the  form  of  suggestion,  moderate 
physical  and  intellectual  labor,  etc.,  is  of  great  service 
during  convalescence,  but  is  contraindicated  during  the 
acute  period  of  the  disease. 

§  3.     Mixed  Types 

Attacks  of  Mixed  Form,  Properly  so  Called. — Kraepelin 
has  thrown  light  upon  the  true  nature  of  these  cases,  which 
are  more  frequent  than  is  generally  supposed  and  in  which 
the  symptoms  of  excitement  and  of  depression  appear  in 
the  same  patient  at  the  same  time. 

In  one  group  of  cases  the  usual  signs  of  depression 
are  associated  with  extreme  mobility  of  attention  and 
veritable  flight  of  ideas.  The  patients  complain  that  the 
direction  of  their  thoughts  escapes  them.  "  My  head 
always  wanders,"  said  one  such  patient:  "I  cannot  fix 
my  attention  upon  anything."  Occasionally  there  is 
melancholic  logorrhoea.  Many  depressed  patients  show  a 
surprising  prolixity  and  harass  those  about  them  by  un- 
ceasing incoherent  lamentations  about  their  unhappy 
lives.^ 

In  a  second  group  of  cases  the  disease  presents  itself 
with  the  characteristics  of  manic  stupor  (Kraepelin).  The 
psychic  paralysis  is  associated  with  more  or  less  pronounced 
1  Kraepelin.     Loc  cit.,  p.  545. 


282  MANIC-DEPRESSIVE  PSYCHOSES 

excitement :  the  patient  is  constantly  moving,  disarranges  his 
bed,  tears  his  clothes,  soils  the  walls  of  his  room,  and  at  the 
same  time  shows  such  dulling  of  the  mind  that  even  the 
simplest  questions  put  to  him  remain  unanswered. 

Finally,  in  a  third  group,  inhibition  is  less  pronounced, 
and  the  elated  mood  of  mania  is  replaced  by  an  uneasy, 
gloomy,  irritable  one,  the  basis  of  which  is  sadness,  like 
in  the  depressed  type. 

The  mixed  type  sometimes  persists  through  the  entire 
duration  of  the  attack.  More  frequently  it  is  met  with 
in  the  transition  periods  of  circular  psychoses,  where  the 
patient  wavers,  so  to  speak,  between  excitement  and  de- 
pression. 

Attacks  of  Double  Form. — Each  attack  here  consists 
of  two  periods:  a  period  of  depression  and  one  of  excite- 
ment.    It  usually  begins  with  the  depression. 

The  transition  from  depression  to  excitement  occurs 
either  suddenly — a  patient  goes  to  bed  a  melancholiac 
and  rises  the  next  morning  a  maniac^or  gradually,  with 
an  intervening  period  of  a  mixed  condition,  as  mentioned 
above.  The  psychomotor  inhibition  gradually  becomes  less 
prominent  and  is  replaced  by  excitement;  flight  of  ideas  and 
logorrhoea  appear.  Finally  the  sadness  disappears  and 
elation  replaces  it. 

When  a  maniac  falls  into  depression  the  same  transi- 
tion occurs  inversely. 

The  treatment  of  each  phase  comprises  the  same  indi- 
cations as  for  attacks  of  simple  depression  and  of  mania 
respectively. 

§  4.    General  Course — Prognosis — General  Consider- 
ations— Treatment 

Manic-depressive  attacks  present  a  very  marked  tendency 
to  recur.  According  to  the  particular  forms  assumed  by  the 
successive  attacks,  several  types  of  manic-depressive  psy- 
choses are  distinguished. 


GENERAL  COURSE  283 

(A)  Periodic  psychoses: 
(a)  Recurrent  mania; 

(6)  Recurrent   depression. 

(B)  Alternating  psychoses. 

(C)  Psychoses  of  double  form. 

(D)  Circular  psychoses. 

(E)  Irregular  forms. 

(A)  Periodic  Psychoses. — (a)  Recurrent  Mania. — The 
attacks  are  always  of  the  manic  type  and  are  separated 
from  each  other  by  normal  periods.  The  number  of  attacks 
and  the  duration  of  the  normal  periods  vary  greatly.  Some 
patients  have  but  two  or  three  attacks  during  their  lifetime; 
it  is  altogether  exceptional  for  an  individual  to  have  but  one 
attack,  at  least  if  his  life  is  a  long  one.  In  all  likelihood  non- 
recurring mania  does  not  exist. 

In  other  cases  the  attacks  follow  each  other  at  brief 
intervals  and  with  a  certain  regularity. 


Excitement                    Exciterrrent                        Esofie) 

menf 

TTormal     /                   \Normal/                     \Normal/^ 

\ 

Normal 

State                                   State                              State 

Scheme  1. — Recurrent  Mania. 

State 

(6)  Recurrent  Depression. — Less  frequent  than  the  pre- 
ceding, this  form  is,  so  to  speak,  its  counterpart.  What  has 
been  said  about  recurrent  mania  is  applicable  to  recurrent 
depression. 

Normal  Normal  NoTmai  NoVmal 

Btate       V  /State  \  /  State  \  /     State 

Uepxesoioa  Depression  Depression 

Scheme  2. — Recurrent  Depression. 

(B)  Alternating  Psychoses. — Attacks  of  mania  and 
those  of  depression  alternate  and  are  separated  from  each 
other  by  normal  intervals. 

Excitement 

Normal  /  \  Normal  Norn  

State  -  State  \  /State  Btate\  7" 

Depression  l>epression 

Scheme  3. — Alternating  Psychosis. 


284  MANIC-DEPRESSIVE  PSYCHOSES 

(C)  Psychoses  of  Double  Form. — Each  attack  consists 
of  a  period  of  depression  and  one  of  excitement;  the  attacks 
are  separated  from  each  other  by  normal  intervals. 


Excitement                               Egpltg 

ment                   Excftement 

Normal                    /               VNormal                  / 

\  ITormal         /            \  Normal 

State    \               /                    State  \               / 

State  \            /                    Stat© 

\          /                                \ / 

Seprefisioo.                              Depressicm. 

Depcession 

Scheme  4. — Psychosis  of  Double  Form. 

(D)  Circular  Psychoses. — Attacks  of  double  form  follow 
each  other  without  interruption. 


Excitement 


Depression  Depression  Depression  Depressloa, 

Scheme  5.— Circular  Psychosis. 

(E)  Irregular  Forms. — These  are  most  frequent.  The 
attacks  follow  each  other  without  order  or  regularity, 
assuming  at  random  the  depressed,  manic,  or  mixed  form. 

Finally,  one  may  observe  the  periodic,  circular,  and 
irregular  forms  combine  in  a  complex  manner,  so  that,  for 
instance,  a  patient  with  a  circular  psychosis  becomes  a 
periodic  maniac-  for  a  time,  or  a  patient  whose  previous 
attacks  have  all  been  of  the  manic  type  presents  an  attack 
of  depression. 

It  is  quite  frequent,  though  not  constant,  to  see  attacks 
of  the  same  type  present  each  time  the  same  aspect:  a 
manic  attack  resembles  previous  ones  in  the  same  patient, 
and  it  is  very  probable  that  the  future  manic  attacks  will 
present  the  same  features. 

The  general  prognosis  of  the  disease  is  not  favorable. 
The  attacks  have  in  some  cases  a  tendency  to  come  closer 
together,  so  that  the  normal  intervals  became  gradually 
shorter  and  shorter  until  they  are  either  totally  wanting  or 
almost  so. 

Etiology. — Manic-depressive     psychoses    are    common. 


DIAGNOSIS  285 

According  to  Kraepelin  they  represent  about  15%  of  all 
admissions  to  psychopathic  hospitals. 

The  causes  are  not  fully  known;  the  essential  feature 
in  the  etiology  seems  to  be  a  constitutional  predisposition 
which  is  beheved  to  be  inherited.  The  heredity  is  often 
similar. - 

The  predisposition  to  have  manic-depressive  attacks 
seems  to  be  observed  with  particular  frequency  in  persons  of 
certain  fairly  well  defined  mental  make-up;,  such  make-up 
is  characterized  either  by  a  constitutional  pessimism,  gloomy 
or  worrisome  disposition,  or,  on  the  contrary,  by  a  happy, 
exuberant,  demonstrative  temperament,  or,  finally,  by  emo- 
tional instability  consisting  of  exaggerated  reactions  to  situ- 
ations by  despair,  discouragement,  or  by  premature  and  un- 
warranted display  of  triumph  and  hopefulness,  as  the  case 
may  be.  This  was  pointed  out  by  Hoch,^  who  has  empha- 
sized particularly  the  contrast  which  such  personalities 
present  to  that  type  of  personality — the  "  shut-in  person- 
ality " — which  he  has  defined  as  being  particularly  prone 
to  develop  dementia  prsecox.^  In  a  more  recent  study 
Reiss  has  arrived  at  similar  conclusions:'*  "  Upon  a  survey 
of  the  whole  material  which  has  been  at  my  disposal,  I  find  as 
a  general  fact  that  in  cases  of  happy  disposition  manic 
states,  while  in  those  of  pronounced  depressive  disposition 
the  sad  melancholy  states  predominate." 

The  age  at  which  the  first  attack  occurs  is  not  constant. 
In  most  cases  it  is  before  the  twenty-fifth  year,  in  some 
before  the  tenth,  and  in  others  after  the  fiftieth.  Quite 
frequently  in  women  the  disease  appears  with  the  onset 
of  menstruation  or  with  the  first  pregnancy. 

Diagnosis. — The    principal  elements   of    diagnosis    are: 

1 C.  B.  Davenport.  Inheritance  of  Temperament.  Washington, 
1915. 

2  Journ.  of  Nerv.  and  Ment.  Dis.,  Apr.,  1909. 

3  See  p.  259. 

*  Eduard  Reiss.  Konstitutionelle  Verstwimung  und  manisch-depres- 
sives  Irresein.  Zeitschr.  f.  die  gesamte  Neurol,  u.  Psychiatrie,  Vol.  II, 
p.  600,  1910. 


286  MANIC-DEPRESSIVE  PSYCHOSES 

psychic  paralysis  associated  with  the  special  symptoms  of 
exaggerated  mental  automatism,  which  have  already  been 
described;  absence  of  mental  deterioration;  recm'rency  of 
the  attacks  with  restitutio  ad  integrum  after  each. 

We  differentiate: 

General  paralysis  by  the  mental  deterioration,  a  certain 
degree  of  which  persists  even  during  the  remissions;  the 
physical  signs;  and  lumbar  puncture  findings; 

Involutional  •melancholia  by  the  intense  and  persistent 
psychic  pain,  which  is  much  more  marked  than  in  the 
depressed  form  of  manic-depressive  psychoses; 

Acute  confusion  by  its  special  etiologj'-,  and  by  the  much 
more  marked  disorientation; 

Delirium  tremens  by  its  specific  hallucinations; 

Dementia  prcecox  by  the  rapid  and  pronounced  diminu- 
tion of  affectivity,  by  catatonic  phenomena,  and  by  the 
absence  of  flight  of  ideas  even  in  those  cases  which  closely 
resemble  mania. 

Homogeneity  of  Manic-Depressive  Psychoses. — Funda- 
mental Sjmiptoms. — The  conception  of  manic-depressive 
psychoses  is  due  to  Kraepelin  and  constitutes  one  of  the  most 
important  advances  in  psychiatry.  Although  the  grouping 
of  such  apparently  different  and  even  opposite  pathological 
states  as  depression  and  mania  may  appear  unreasonable 
on  superficial  consideration,  its  legitimacy  is  nevertheless 
incontestable  and  is  based  on  two  principal  considerations: 

(1)  The  existence  of  certain  fundamental  symptoms 
common  to  all  forms,  manic,  depressed,  and  mixed. 

(2)  The  alternation,  regular  or  not,  as  the  case  might 
be,  of  the  phenomena  of  excitement  and  depression  in  the 
same  subject. 

(1)  Fundamental  Symptoms. — The  symptoms  of  manic- 
depressive  psychoses  can  be  readily  divided  into  two  groups. 

The  first  group  comprises  all  the  morbid  phenomena 
dependent  on  psychic  paralysis,  namely:  (a)  weakening 
of  attention;  (6)  sluggish  formation  of  associations  of  ideas; 
(c)  insufficiency  of  perception;  (d)  pathological  indifference. 


FUNDAMENTAL  SYMPTOMS  287 

These  symptoms  of  psychic  paralysis  are  especially 
prominent  in  the  depressed  type.  But  in  mania,  though 
usually  masked  by  phenomena  of  exaggeration  of  mental 
automatism  (flight  of  ideas,  motor  excitement),  they  are, 
nevertheless,  also  present,  as  can  be  readily  shown  by  a  care- 
ful examination. 

Let  us  consider  these  symptoms  individually. 
.  (a)  Weakening    of    Attention. — Abnormal    mobility    of 
attention  is  one  of  the  fundamental  symptoms  of  mania. 
Yet,  as  shown  in  the  first  part  of  the  book,  this  is  but  a  mani- 
festation of  weakening  of  attention. 

(6)  Sluggish  Formation  of  Associations  of  Ideas. — 
Kraepelin  ^  and  his  pupils  have  shown  by  means  of  psy- 
chometry  that  the  acceleration  of  mental  processes  in 
mania  affects  only  automatic  processes,  voluntary  associa- 
tions of  ideas  being  actually  retarded,  just  as  they  are  in 
the  depressed  states. 

(c)  Insufficiency  of  Perception. — Perception  of  the  ex- 
ternal world  is  inaccurate  in  depression  as  well  as  in  mania; 
but  while  in  the  former  case  the  perceptions  are  often  incom- 
plete and  are  manifested  clinically  by  uncertainty,  in  the  latter 
case  automatic  associations  occur  in  the  place  of  missing 
normal  ones  and  give  rise  to  false  perceptions  or  illusions. 
Neither  the  melancholiac  nor  the  maniac  perceives  the 
phenomena  of  the  external  world  in  their  true  aspect,  but  the 
one  remains  in  doubt  while  the  other  affirms  errors. 

(d)  Pathological  indifference  also  clearly  exists  in  mania 
as  well  as  in  depression.  To  be  convinced  of  this,  it  suffices 
but  to  recall  the  perfect  serenity  with  which  the  maniac 
receives  news  of  a  misfortune  in  his  family  which,  in  the 
normal  state,  would  profoundly  distress  him. 

Psychic  inhibition  expressed  by  the  above  four  symptoms 
is,  therefore,  the  fundamental  and  constant  disorder  con- 

1  Psychiatrie,  7th  edition,  Vol  II.  p.  504.  On  the  subject  of  measure- 
ment of  the  rapidity  of  the  associations  in  the  insane,  particularly  in 
circular  insanity,  see  also  Ziehen's  contribution  in  Neurol.  Centralbl., 
1896. 


288  MANIC-DEPRESSIVE  PSYCHOSES 

stituting  the  common  basis  of  the  diverse  cHnical  types  of 
attacks  of  manic-depressive  psychoses. 

The  symptoms  of  the  second  group  are  dependent,  not 
upon  psychic  inhibition,  but  upon  exaggerated  mental  autom- 
atism, which  so  often  accompanies  it.  The  principal 
symptoms  of  this  group  are:  (a)  Flight  of  ideas;  (6)  irrita- 
bility; (c)  impulsive  reactions;  {d)  delusions  and  psycho- 
sensory disorders;  (e)  fixed  ideas  and,  occasionally,  im- 
perative ideas. 

All  these  morbid  phenomena  are  incidental.  Their 
presence  or  absence  modifies  the  aspect  but  not  the  nature 
of  the  attack.  Some  appear  with  equal  frequency  in  mania 
and  in  depression,  namely,  delusions  and  hallucinations. 
Others  are,  on  the  contrary,  peculiar  either  to  the  one  or  to 
the  other  of  these  states:  flight  of  ideas,  irritability,  im- 
pulsiveness to  mania,  fixed  ideas  to  depression.  But  there 
is  no  absolute  rule  in  this  respect;  we  meet  with  depressed 
cases  with  flight  of  ideas,  and  with  cases  of  mania  in  which 
the  delusions  are  more  or  less  fixed. 

(2)  Alternation  of  Excitement  and  Depression  in  the 
Same  Patient. — The  close  relationship  existing  between 
states  of  depression  and  manic  states  becomes  still  more 
evident  when,  instead  of  considering  a  single  attack,  we 
make  a  study  of  all  the  attacks  of  one  patient.  First  of  all, 
it  is  extremely  rare  for  a  patient  to  have  only  one  attack  of 
mania  or  of  depression  in  his  life.  Thus  isolated  and  non- 
recurring mania  or  depression  is  almost  eliminated.  In 
some  cases,  it  is  true,  the  attacks  are  always  manic,  while 
in  some  others  they  are  always  depressed.  These  two 
groups  apparently  separated  by  an  unfathomable  abyss, 
are  in  reality  connected  by  a  much  larger  group  of  double, 
alternating,  circular,  and  irregular  forms,  which  establish  an 
insensible  transition  from  the  one  to  the  other.  Moreover, 
a  close  study  of  cases  shows  that  the  majority  of  attacks 
presenting  the  manic  type  or  the  depressed  type  are  in  reality 
attacks  of  double  form.  In  fact,  on  careful  inquiry  we 
find  that  almost  constantly  manic  symptoms  are  preceded 


TREATMENT  289 

by  a  prodromal  period  characterized  by  more  or  less  marked 
depression;  again,  we  often  find  an  attack  of  depression  to 
be  followed  by  a  state  of  excitement  which  cannot  be  attrib- 
uted to  any  known  cause,  not  even  to  the  patient's  prospect 
of  returning  to  his  usual  mode  of  life  in  the  near  future. 
Thus  all  attacks  of  mania  and  of  depression  contain  in  a 
rudimentary  form  the  elements  of  excitement  and  of  depres- 
sion. Circular  psychoses  thus  become  the  prototype  from 
which  the  other  types  are  derived. 

The  above  considerations  show  us  that,  in  spite  of  the 
apparent  diversity  of  the  symptoms,  mania,  depression, 
and  their  various  combinations  are  not  to  be  considered,  as 
heretofore,  as  different  morbid  entities,  and  that  the 
following  conclusion  arrived  at  by  Kraepelin  is  perfectly 
justifiable : 

"  The  diverse  forms  which  have  been  described  are 
but  different  manifestations  of  one  and  the  same  fundamental 
pathological  process,  equivalents,  like  the  many  forms  assumed 
by  epileptic  paroxysms."  ^ 

Treatment. — For  the  treatment  of  the  symptoms  which 
may  arise  in  the  different  phases  of  manic-depressive  psy- 
choses the  reader  is  referred  to  Chapter  VIII,  Part  I,  of  this 
Manual. 

As  to  the  problem  of  prevention  of  recurrency  it  is  im- 
portant to  insist  Dn  abstinence  from  all  alcoholic  beverages. 
A  single  drink  of  whiskey  has  been  known  to  act  as  the 
undoubted  cause  of  an  attack  in  a  manic-depressive  in- 
dividual, and  there  are  some  cases  in  which  most  of  the  at- 
tacks are  attributable  to  over-indulgence  in  alcohol. 

An  attempt  has  been  made  by  Kohn  to  prevent  the 
recurrency  of  attacks  in  cases  in  which  the  outbreaks  are 
brief  and  frequent  and  occur  with  such  regularity  that  the 
date  of  their  onset  can  be  predicted  with  more  or  less  accu- 
racy. In  such  cases,  beginning  several  days  before  the 
expected  attack,  the  patient  is  given  from  12  to  15  grams 

1  Kraepelin.     Psychiatrie,  7th  edition,  Vol.  II,  p.  558. 


290  MANIC-DEPRESSIVE  PSYCHOSES 

of  sodium  bromide  daily  until  the  "  danger  period  "  is  over, 
when  the  dose  is  gradually  diminished  and  the  drug  finally 
discontinued.  It  seems  in  some  cases  possible  to  prevent 
the  outbreaks  of  excitement  by  this  method  of  treatment. 


§  5.     Chronic  Mania 

The  diagnosis  of  chronic  mania  was  at  one  time  one  of 
the  most  common  in  psychiatry.  To-day  there  can  be  no 
doubt  that  many  cases  formerly  thus  labeled  belong  to  excited 
forms  of  dementia  prsecox,  particularly  catatonic  excitements : 
many,  but  not  all.  Chronic  mania,  though  rare,  certainly 
infinitely  more  rare  than  was  believed  by  older  authors, 
constitutes  none  the  less  a  reality.  Cases  exist  presenting 
all  the  symptoms  characteristic  of  the  manic  state — flight 
of  ideas,  excitement,  morbid  irritability,  pressure  of  activity, 
etc. — and  in  which  these  symptoms,  instead  of  being  inter- 
mittent, become  established  in  definitely  chronic  fashion. 

Chronic  forms  are  seen  chiefly  in  elderly  subjects,  after 
the  age  of  fifty.  It  is  exceptional  for  a  chronic  manic  state 
to  be  installed  as  such  from  the  beginning.  More  often  it 
follows  one  or  more  acute  attacks.  The  patient  has  one, 
two,  three  attacks  from  which  he  recovers  completely; 
then  comes  on  another  attack  in  every  way  resembling  the 
previous  ones;  the  excitement  subsides  somewhat,  periods 
of  relative  calm  occur  at  intervals;  recovery  seems  to  be 
approaching,  but  the  condition  continues  indefinitely  and 
it  finally  becomes  apparent  that  the  acute  maniac  has  become 
a  chronic  maniac.  At  times  the  chronic  state  is  marked 
by  extreme  weakness  of  attention;  this  was  observed  in  the 
following  case,  the  history  of  which  we  shall  cite  briefly, 
and  which  may  serve  as  a  general  type: 

Mrs.  C.  J.,  two  of  whose  cousins  are  insane,  was  born  in  1844. 
In  1869,  that  is,  at  the  age  of  twenty-five  years,  following  a  confine- 
ment, she  had  an  attack  consisting  of  a  period  of  depression  and  one 
of  excitement,  the  whole  attack  lasting  eighteen  months.     She  recovered 


CHRONIC  MANIA  291 

and  remained  well  until  1891,  when,  without  apparent  cause,  she  had  a 
similar  attack  from  which  she  recovered  at  the  end  of  two  years,  fol- 
lowing a  surgical  operation  upon  the  uterus.  In  1901  a  third  attack: 
period  of  depression  lasting  several  months,  later,  following  a  trip  on 
w'hich  she  was  taken  for  diversion,  sudden  appearance  of  the  manic  state. 
Another  surgical  operation  upon  the  uterus  was  tried,  but  without 
any  result.  Since  1901  excitement,  flight  of  ideas,  and  logorrhcea 
have  persisted  with  intervals  of  lucidity  which  gradually  became  rarer 
and  shorter.  These  intervals,  which  at  first  lasted  several  days,  have 
not  lasted  longer  than  one  or  two  hours  during  the  first  half  of  1908. 
At  the  present  time  (September,  1908)  they  hardly  exceed  half  an  hour 
and,  as  already  stated,  they  are  notably  more  rare  than  during  the  first 
year  of  the  disease.  Moreover,  even  in  the  moments  of  lucidity  which 
stUl  occur  from  time  to  time,  a  certain  degree  of  mental  deterioration 
is  observed.  Affectivity  is  reduced,  recollections  are  lacking  in  pre- 
cision, attention  is  fixed  with  some  difficulty,  and  orientation  of  time  is 
defective.  There  seems  to  be  no  doubt  that  we  are  here  dealing  with  a 
state  of  chronic  mania  with  slight  mental  deterioration.  The  most 
pronoimced  disorder,  the  one  which  especially  characterizes  the  case  in 
question  and  distinguishes  it  from  ordinary  manic-depressive  cases 
is  an  extreme  weakness  of  attention,  a  weakness  which  is  out  of  all  pro- 
portion to  the  motor  excitement,  and  which  makes  it  impossible  to 
obtain  a  sensible  reply  even  to  the  simplest  questions,  whUe  at  the 
same  time  it  is  easy  to  obtain  relative  psychomotor  calm,  sufficient, 
for  instance,  to  keep  the  patient  seated  in  a  chair. 


CHAPTER  VII 
INVOLUTIONAL  MELANCHOLIA 

The  essential  cause  of  this  disease  seems  to  be  bad 
heredity.  Among  other  factors  those  most  frequently 
mentioned  are  grief  and  stress.  Occurring  chiefly  after 
forty-five  years  of  age,  it  seems  to  be  in  some  way  connected 
with  the  phenomena  of  organic  retrogression  beginning  at 
this  age;  hence  the  name  "  involutional  melancholia." 

The  prodromal  period,  which  is  almost  constant  and 
usually  very  long,  indicates  a  profound,  slow,  and  progressive 
change  of  the  entire  organism:  the  process  of  digestion  is 
painful;  there  are  anorexia,  insomnia,  irritability,  unwar- 
ranted pessimism,  and  a  tendency  to  rapid  fatigue. 

Finally  the  disease  sets  in,  characterized  from  the  begin- 
ning by  intense  psychic  pain. 

It  presents  itself  with  the  train  of  physical  and  psychic 
symptoms  already  studied  in  connection  with  active  depres- 
sion. When  associated  with  anxiety  it  gives  rise  to  anxious 
melancholia.^ 

The  anxiety  may  result  either  in  agitation  (melancholia 
agitata)  or  in  stupor.  In  the  latter  case  the  patient  appears  as 
though  dumbfounded  by  the  pain.  "  A  frightful  internal 
anxiety  constitutes  the  fundamental  state,  which  torments 
him  almost  to  suffocation."  ^ 

When  the  psychic  pain  is  very  marked,  it  entails  some- 
times a  certain  degree  of  mental  confusion  which  is  most 

^  Capgras.  Essai  de  reduction  de  la  melancolie  a  une  psychose 
d'involution  presenile.  These  de  Paris,  1900. — Kraepelin.  Lehrbuch 
der  Psychiatrie. 

2  Griesinger.     Loc.  cit.,  p.  292. 

292 


SYMPTOMS  293 

frequently  transitory  and  subject  to  the  same  fluctuations 
as  the  pain  itself  of  which  it  is  a  manifestation. 

In  cases  of  slight  or  moderate  intensity  lucidity  is  perfect 
and  sometimes  permits  the  patient  to  analyze  his  case  with 
considerable  minuteness. 

Association  of  ideas  is  sluggish,  less  so,  however,  than  in 
the  depressed  form  of  manic-depressive  psychoses.  We 
have  seen,  in  fact,  that  the  intensity  of  psychic  inhibition 
is  inversely  proportional  to  that  of  psychic  pain;  accordingly 
the  inhibition  occupies  here  a  secondary  position.  Between 
the  cases  in  which  the  sadness  clearly  predominates  and 
those  in  which  the  inhibition  is  the  principal  feature,  there 
is  a  host  of  intermediary  forms  which  establish  an  insensible 
transition  between  involutional  melancholia  and  manic- 
depressive  psychoses.  These  two  affections  seem  to  be 
closely  related,  and  borderland  cases  are  not  uncommon. 

The  recent  study  of  Dreyfus  ^  indicates  clearly  that 
the  relationship  between  involutional  melanchoHa  and  manic- 
depressive  psychoses  is,  indeed,  a  close  one.  This  study  con- 
sists in  a  careful  investigation  of  the  entire  subsequent 
course  of  all  cases  admitted  to  the  Heidelberg  cUnic  since 
1892  and  classified  as  involutional  melanchoHa.  The 
facts  revealed  by  the  investigation  are:  the  great  majority 
of  the  cases  which  had  not  terminated  in  death  through 
some  complication  resulted  in  complete  recovery;  in  a  small 
percentage  of  the  cases  deterioration  ultimately  occurred 
apparently  on  a  basis  of  cerebral  arteriosclerosis  which 
such  cases  seem  to  be  particularly  prone  to  develop;  more 
than  half  of  the  cases  had  more  than  one  attack;  in  many 
cases  manic  symptoms  were  observed:  fleeting  euphoria, 
irritability,  loquaciousness,  flight  of  ideas,  etc.  These 
results  led  Dreyfus  to  the  conclusion  that  involutional 
melanchoHa  was  but  a  special  mixed  form  of  manic-depres- 
sive psychoses  and  Kraepelin,  in  a  preface  contributed 
to  the  work  of  Dreyfus,  evidently  accepts  this  conclusion 

1  Die  Melancholie  ein  Zustandsbild  des  manisch-depressiven  Irresdns. 
Jena,  1907. 


294  INVOLUTIONAL  MELANCHOLIA 

in  the  following  words:  "  These  results  show,  at  least  for 
the  main  bulk  of  the  cases  which  we  have  designated  as 
involutional  melancholia,  that  there  is  no  longer  any  basis 
compelling  their  separation  from  manic-depressive  psy- 
choses." 

Thus  it  would  seem  that  the  autonomy  of  involutional 
melancholia  as  a  separate  clinical  entity  is  destroyed. 
We  have,  however,  allowed  the  description  of  it  in  this 
Manual  to  remain,  partly  for  the  reason  that  it  still  figures 
in  hospital  statistics,  but  mainly  for  the  reason  that,  admit- 
ting its  kinship  to  manic-depressive  psychoses,  it  never- 
theless presents  special  and  characteristic  features,  among 
which  may  be  mentioned  its  frequent  development  following 
actual  depressing  causes  (death  of  a  near  relative,  financial 
ruin);  its  grave  form  characterized  by  long  duration  (in 
many  cases  over  five  years,  in  some  over  ten  years),  frequent 
fatal  termination ;  combinations  of  symptoms  not  commonly 
observed  in  typical  attacks  of  manic-depressive  psychoses; 
the  occurrence  in  nearly  half  of  the  cases  of  only  one  attack 
during  the  life  of  the  individual. 

The  sadness  may  in  itself  become  a  cause  of  psychic  in- 
hibition and  create  melancholia  with  stupor. 

To  these  psychic  phenomena  are  added  physical  dis- 
orders most  of  which  have  already  been  considered : 

Respiratory  and  circulatory  disturbances  which  are 
dependent  upon  the  depression  and  anxiety. 

Disturbances  of  digestive  functions;  anorexia,  dyspepsia, 
painful  digestion,  constipation. 

Impairment  of  the  general  nutrition,  changes  in  the 
composition  of  the  urine  (diminution  of  urea,  slight  albu- 
minuria), and  rapid  loss  of  flesh.  The  latter  symptom  is  of 
particular  importance;  a  rise  in  weight  usually  indicates 
beginning  convalescence. 

The  menses  are  usually  suppressed.  Their  reappear- 
ance has  the  same  prognostic  significance  as  the  return 
of  the  normal  weight;  it  indicates  the  approach  of  re- 
covery. 


SYMPTOMS  295 

Finally,  there  are  various  nervous  troubles:  headache, 
palpitation,  tremors,  hysteriform  crises,  and  insomnia. 

These  are  the  fundamental  symptoms  of  involutional 
melancholia  in  its  simplest  form  and  uncomplicated  by 
delusions.  This  form  is  rare;  generally  the  disease  assumes 
one  of  the  following  two  forms,  or  some  combination  of  the 
two:   anxious  melancholia  and  delusional  melancholia. 

Anxious  Melancholia. — The  psychic  pain,  which  is  here 
very  intense,  manifests  itself  by  the  mental  and  physical 
symptoms  of  anxiety,  which  have  already  been  described 
in  the  first  part  of  this  book :  more  or  less  complete  cessation 
of  mental  processes,  in  some  cases  a  certain  degree  of  mental 
confusion  at  the  time  of  the  paroxysms  of  anxiety;  an  ex- 
tremely distressing  sense  of  constriction  generally  localized 
in  the  precordial  region  or  in  the  throat,  less  often  in  the 
head;  pallor  and  pinched  expression  of  the  face,  coldness 
and  cyanosis  of  the  extremities,  irregular  and  shallow 
respirations;  lowering  of  blood  pressure ;  small,  compressible 
pulse,  either  rapid  or  slow;  dilatation  of  the  pupils. 

From  the  point  of  view  of  the  reactions  anxious  melan- 
cholia is  characterized  either  by  agitation  or  by  stupor. 

The  agitation  of  melancholia  presents  the  appearance 
of  despair:  the  patient  wrings  his  hands,  strikes  his  head 
against  the  walls,  and  gives  vent  to  cries  and  lamentations. 
It  is  monotonous  and  often  marked  by  very  pronounced 
negativism.  The  phenomena  of  agitation  are  sometimes 
purely  impulsive  in  origin  and  occur  in  the  shape  of  sudden 
attacks  which  may  be  very  brief.  During  such  attacks 
the  patients  may  display  a  tendency  to  violent  acts  of 
danger  to  themselves  or  to  others  (suicidal  or  homicidal 
attempts).  Such  paroxysms  constitute  the  so-called  raptus 
melancholicus. 

Psychic  pain  may,  like  physical  pain,  paralyze  more  or 
less  completely  all  mental  functions.  Thus  is  explained  the 
manner  in  which  anxious  melancholia  may  become  trans- 
formed into  stuporous  melancholia;  these  two  forms,  seem- 
ingly so  different,  are  in  reality  closely  related.     The  psychic 


296  INVOLUTIONAL  MELANCHOLIA 

inhibition  which  characterizes  stuporous  melancholia  is 
essentially  a  secondary  phenomenon. 

Anxious  melancholia  sometimes  exists  in  a  state  of 
purity,  either  as  agitated  melancholia  or  as  stuporous  melan- 
cholia.    Much  more  often  it  is  complicated  by  delusions. 

Delusional  Melancholia. — All  varieties  of  melancholy 
delusions  are  encountered  in  this  affection:  ideas  of  cul- 
pability, of  humility,  of  ruin,  hypochondriacal  ideas,  and 
ideas  of  negation.  It  is  not  uncommon  for  persecutory 
ideas  to  occur  in  combination  with  the  melancholy  ideas. 

Hallucinations  are  not  frequent.  The  least  rare  are, 
according  to  Seglas,  those  of  vision  and  of  the  muscular 
sense.  Those  of  hearing,  taste,  and  smell  are  occasionally 
met  with,  while  those  of  general  sensibility  are  altogether 
exceptional. 

Illusions  of  all  sorts  are,  on  the  contrary,  frequent. 
They  often  assume  the  form  of  mistakes  of  identity. 

Finally,  delusional  interpretatiojis  are  constant.  The 
patient  hears  the  noise  of  hammer-strokes  in  the  vicinity 
and  thinks  a  scaffold  is  being  built  for  him.  He  hears  the 
sound  of  voices  in  the  street  and  thinks  the  mob  is  going 
to  seize  and  lynch  him,  etc. 

The  reactions  are  usually  in  harmony  with  the  melan- 
choly state  and  with  the  nature  of  the  delusions.  Some- 
times, under  the  influence  of  anxiety  which  in  many  cases 
accompanies  the  delusions,  the  reactions  assume  an  ex- 
clusively automatic  character;  it  is  to  be  noted  that  nega- 
tivism is  not  uncommon. 

The  following  case  illustrates  both  delusional  and  anxious 
melancholia: 

Margaret  L.,  fifty-eight  years  old. — Paternal  and  maternal  hered- 
ity: father  was  alcoholic,  died  of  disease  of  the  liver;  mother  eccentric, 
vmduly  irritable;  maternal  aunt  committed  suicide.  —  The  patient 
has  always  been  nervous  and  sensitive.  She  has  been,  however,  of 
normal  intelligence  and  always  attended  properly  to  the  work  of  her 
home  and  family.  She  has  two  daughters,  respectively  thirty  and 
twenty-five  years  old,  both  normal.  Menstruation  ceased  two  years 
ago. 


SYMPTOMS  297 

The  mental  symptoms  began  with  a  state  of  general  depression 
and  discouragement.  On  being  invited  to  a  christening  of  a  little 
boy  she  refused  to  go,  giving  as  her  reason  that  life  is  a  burden  and 
that  there  is  no  cause  for  rejoicing  in  the  birth  of  a  child.  After  several 
weeks  she  began  to  show  very  marked  uneasiness  and  a  httle  later 
delusional  interpretations.  She  saw  wagons  passing  by  the  house 
loaded  with  various  objects,  furniture,  bedding,  barrels,  sacks  of  flour; 
she  heard  the  drivers  cracking  their  whips;  all  this  alarmed  her  greatly 
and  she  asked  her  husband  whether  all  this  did  not  signify  that  she 
was  to  be  thrown  out  of  the  house  and  left  to  starve  to  death.  She 
noticed  also  that  the  neighbors  looked  at  her  queerly  whenever  she  met 
them.  At  the  same  time  physical  symptoms  appeared:  complete  loss 
of  appetite,  headache,  insomnia.  About  two  weeks  later,  namely, 
March  20,  1900,  she  developed  an  idea  of  self-accusation.  About 
twenty-five  years  ago  she  lost  a  httle  daughter  from  croup.  Did  not 
this  child  die  because  its  mother  had  left  it  one  day  with  its  feet  wet? 
This  idea  at  first  had  the  character  of  an  imperative  idea;  the  patient 
knew  it  was  false  and  tried  to  drive  it  away;  it,  however,  grew  more 
and  more  dominating  and  was  finally  accepted  by  the  patient  as  true: 
the  imperative  idea  had  become  a  fixed  idea.  The  psychic  pain  increased 
steadily.  New  delusions  sprang  up,  the  first  one,  however,  still  remain- 
ing active.  On  April  12  the  patient  went  to  the  police  headquarters 
carrying  a  bundle  of  clothing;  this,  she  said,  was  for  the  poor  girls  who 
had  been  robbed  of  everything  and  thrown  out  in  the  street.  At  the 
same  time  she  begged  the  police  authorities  to  send  men  to  protect 
those  unfortunate  women  whom  the  Prussians  were  about  to  ravish. 

On  being  taken  to  a  sanatorium  she  did  not  cease  to  wail  and  to 
lament,  first  accusing  herself,  as  formerly,  of  the  death  of  her  httle 
girl,  later  of  the  illness  of  her  husband,  who  really  did  have  heart 
trouble.  Gradually  the  delusions  grew.  She  claimed  she  had  brought 
upon  her  relatives  such  disgrace  and  misery  that  they  aU  committed 
suicide;  the  letters  which  she  is  supposed  to  receive  from  them  are 
false;  no  doubt  this  is  done  to  console  her;  everybody  has  been  too 
good  to  her;  such  a  nasty  creature  should  have  her  head  chopped 
off.  There  she  is,  well  fed  and  housed,  and  warmly  dressed,  yet  they 
know  well  that  she  has  no  money  to  pay  for  all  this.  But  this  cannot 
last;  pretty  soon  the  day  will  come  when  they  will  put  her  out  to  go 
and  beg.  She  developed  a  few  haUuciaations  of  sight,  of  hearing, 
and  of  muscular  sensibility:  several  times  she  saw  before  her  a  pool 
of  blood;  also  several  times  she  heard  the  voices  of  her  children  crying: 
"  Bread!  Give  us  bread!  "  Finally  she  complained  of  an  inner  voice 
coming  from  her  breast,  which  made  her  say  against  her  own  wiU: 
"  Slut!  slut!  "  She  cried  loudly,  begging  to  be  put  to  death;  has  made 
repeated  attempts  to  commit  suicide;  from  April  21  to  October  30 
five  such  attempts  were  counted,  three  of  which  were  by  hanging. 


298  INVOLUTIONAL  MELANCHOLIA 

For  a  time  she  refused  food;  after  being  tube-fed  for  two  days,  she 
began  to  eat  again,  although  with  much  difficulty. 

Considerable  emaciation.  Tongue  coated.  Breath  very  foul. 
Constipation.     Slight  trace  of  albumen  in  the  urine. 

Such  is  the  fundamental  and  habitual  state  of  the  patient.  The 
anxiety,  without  being  ever  entirely  wanting,  presents,  however, 
periods  of  exacerbation,  so  that  the  patient  at  times  shows  the  typical 
picture  of  anxious  melancholia.  During  such  paroxysms  the  patient 
seems  to  be  literally  suffocating.  She  seems  to  be  striving  to  throw 
off  a  weight  from  her  chest;  she  pulls  her  hair,  strikes  herself  in  the  face, 
and  scratches  at  the  walls  of  her  room  untU  her  fingers  bleed.  When 
her  agitation  is  at  its  height  it  is  impossible  to  obtain  from  her  a 
response  to  any  question.  She  merely  utters  inarticulate  cries  or  re- 
peats in  a  low,  scarcely  audible  voice:  "  My  God!  .  .  .  My  God! 
..."  Her  consciousness  is  then  evidently  profoundly  affected  and 
it  seems  that  even  delusions  at  such  times  disappear  under  the  influence 
of  the  psychic  pain  and  anxiety. 

Toward  the  latter  part  of  November,  1900,  the  general  condition 
of  the  patient  improved.  Her  appetite  became  better.  The  delusions 
pe^-^isted  and  the  patient  continued  her  lamentation,  but  the  reactions 
be"a,me  iess  pronounced.  Little  by  little  the  delusions  also  became 
less  active.  A  certain  degree  of  mental  activity  returned.  Toward 
the  middle  of  December  the  patient  was  able  to  do  some  manual  work. 
She  returned  home,  completely  cured,  February  6,  1901.  At  the 
present  time  (1905)  she  is  still  perfectly  well. 

Prognosis.^ — Melancholia  may  terminate  in: 
(a)  Complete  recovery,  67%; 

(6)  Dementia  due  to  the  development  of  cerebral  arteri- 
osclerosis, 8%; 

(c)  Death,  25%  which  may  be  due  to: 

(I)  Suicide,  which  is  the  more  likely  to  occur  the  more 
pronounced  the  psychic  pain  and  the  less  marked  the  in- 
hibition. The  melancholiac  may  commit  suicide  at  any 
period  of  his  illness,  even  during  convalescence,  when  on 
account  of  a  real  or  fictitious  gaiety,  supervision  over  him 
is  relaxed; 

(II)  Melancholic  wasting,  the  principal  factors  of  which 
are  intense  sadness,  anxiety,  agitation,  sleeplessness,  and 
insufficient  alimentation  occasioned  by  a  poor  condition 
of  the  digestive  tract,  a  delusion,  or  a  suicidal  idea; 

1  Dreyfus.     Loc.  cit.,  p.  269. 


TREATMENT  299 

(III)  Some  complication  the  occurrence  of  which  is 
favored  by  the  defective  nutrition  of  the  tissues :  pneumonia, 
influenza,  tuberculosis. 

The  duration  of  the  affection  is  very  variable,  from 
several  weeks  to  a  few  years. 

Treatment. — The  principal  indications  are: 

To  watch  the  patient  with  a  view  to  the  prevention 
of  suicide; 

To  support  his  strength; 

To  calm  agitation  if  there  is  any; 

To  pay  special  attention  to  the  alimentation. 

The  first  three  indications  are  admirably  fulfilled  by 
rest  in  bed. 

Forced  alimentation  is  often  necessary  to  fulfill  the 
fourth. 

Psychic  pain  may  be  efficaciously  combated  by  the 
administration  of  opium  in  increasing  doses.  One  may  start 
with  15  minims  of  the  tincture  per  day,  increase  to  60  minims 
or  more,  and  then  gradually  reduce  the  quantity  to  the 
initial  dose  before  discontinuing  the  treatment. 

Finally,  continuous  warm  baths  may  be  of  service  in 
the  agitated  forms. 


CHAPTER  VIII 

PSYCHONEUROSES 

HYSTERIA— NEURASTHENIA— PSYCHASTHENIA 

§1.    Hysteria 

Many  conditions  with  which  psychiatrists  have  to  deal 
demand  a  certain  broadening  of  the  traditional  conception 
of  disease — that  of  some  morbid  material  or  influence 
engrafted  upon  the  organism.  Among  such  conditions 
are  mental  deficiency  and  constitutional  psychopathic 
states.  Among  them  also  is  hysteria,  which,  far  from  being 
a  disease  in  the  traditional  sense,  is  essentially  mere  simula- 
tion or  assumption  of  disease  or  disability  without  organic 
basis — a  special  type  of  anomalous  behavior. 

The  manifestations  of  hysteria  are  varied,  the  only  limit 
to  their  variation  being  the  limit  of  the  ability  to  produce 
them  by  an  effort  of  the  will  (conscious  or  unconscious). 
Accordingly  such  manifestations  as  elevation  of  temperature, 
muscular  atrophy,  abolition  of  knee  jerks  or  pupillary 
reflexes,  heart  murmurs,  etc.,  do  not  occur  in  uncomplicated 
hysteria. 

It  would,  therefore,  be  to  no  purpose  to  describe  the  clini- 
cal manifestations  of  hysteria.  Some  may  be  mentioned, 
however,  as  being  among  the  most  common:  convulsions, 
tremors,  paralyses,  contractures,  areas  of  hypo-sesthesia 
or  anaesthesia,  mutism,  aphonia,  deafness,  amaurosis, 
amnesia,  psychotic  episodes,  etc. 

In  ordinary  times  hysteria  is  seen  more  frequently  in 
women  than  in  men;  but  during  the  World  War  of  1914- 
1918  a  great  many  cases  occurred  in  soldiers  and  there 

300 


HYSTERIA  301 

was  an  unprecedented  opportunity  of  observing  them  under 
conditions  which  forced  into  view  their  underlying  psychic 
mechanism.  These  cases  correspond  perhaps  most  closely  to 
the  traumatic  hysteria  of  peace  times;  but  it  is  probable 
that  they  do  not  differ  essentially  from  ordinary  hysteria 
occurring  independently  of  trauma. 

The  following  presentation  is  based  mainly  on  war  experi- 
ences. A  brief  restatement,  however,  of  pre-war  current 
conceptions  will  be  given  first. 

Charcot's  conception  of  hysteria  was  that  of  a  disease 
entity.  This  led  to  a  preoccupation  with  symptomatology, 
differential  diagnosis,  clinical  definition,  and  largely  remained 
on  a  descriptive  level. 

Mobius  saw  in  hysteria  not  a  disease  entity,  but  a  biologi- 
cal trait  characterized  by  a  special  type  of  reaction.  "  For 
him  every  one  was  more  or  less  hysterical.  Every  one  has 
hysterical  small  coin  in  the  bank  of  his  personality."  ^ 

Janet's  contribution  consists  essentially  in  the  theory  of 
subconscious  mental  processes.  An  idea  or  a  group  of  ideas 
may  operate  somewhere  beneath  the  threshold  of  conscious- 
ness, i.e.,  without  the  subject  being  clearly  or  at  all  aware  of 
them ;  and  they  may  operate  so  effectively  as  to  largely  con- 
trol the  conduct  of  the  subject.^ 

Further  progress  in  the  analysis  of  hysterical  mechanisms 
is  due  to  Freud. ^  He  attempts  an  explanation  of  the  phe- 
nomenon of  splitting  or  doubling  of  personality  to  which 
Janet  had  called  attention.  Ideas  or  complexes  of  ideas 
are  lodged  in  the  region  of  the  subconscious  not  at  random 
but  by  a  purposeful  functional  process,  which  he  terms 
repression,  by  reason  of  being  charged  with  painful  affect. 
The  important  part  played  by  affect  in  the  etiology  of 

1  Smith  E.  Jelliffe.  Hysteria.  In  Modern  Medicine.  Edited  by 
Osier  and  McCrae,  Vol.  V. 

2  P.  Janet.  The  Mental  State  of  Hystericals.  English  translation 
by  Caroline  R.  Corson.     New  York,  1901. 

^  S.  Freud.  Selected  Papers  on  Hysteria.  English  translation  by 
A.  A.  Brill. 


302  PSYCHONEUROSES 

hysteria  had  long  been  sensed  and  had  been  in  particular 
insisted  on  by  Binswanger.  Freud's  experience  has  led 
him,  moreover,  to  assume  the  universality  of  a  sexual  origin 
of  the  repressed  complexes  underlying  hysterical  manifesta- 
tions. 

"  The  final  principle  of  the  Breuer-Freud  hypothesis  is 
the  principle  of  conversion.  The  strangulated  affect,  the 
unreacted-to  emotion,  belonging  to  the  disassociated  state 
which  has  been  repressed,  finds  its  way  into  bodily  innerva- 
tion, thus  producing  the  motor  phenomena  of  hysteria. 
In  this  way  the  strong  idea  is  weakened  by  being  robbed  of 
its  affect — the  real  object  of  conversion."  ^ 

In  one  respect  Freud's  conception  is  comparable  to  the 
older  one  of  Mobius,  for  Freud,  too,  does  not  regard  hysteria 
as  a  sharply  defined  disease  entity,  but  rather  as  an  exag- 
gerated condition  of  a  mechanism  which  in  lesser  degrees  is 
operative  in  normal  minds. 

There  remains  to  be  mentioned  the  contribution  of 
Babinski  ^  which  has  largely  dominated  the  French  and  some 
other  schools  not  only  in  pre-war  years,  but  even  through  the 
war,  having  apparently  survived  the  light  of  the  great  mass 
of  newly  added  experiences. 

The  essence  of  Babinski's  contribution  consists  in  an 
attempt  to  isolate  from  the  heterogeneous  material  tradi- 
tionally thrown  together  under  the  heading  of  hysteria  the 
elements  of  which  it  is  composed.  An  application  of  more 
careful  diagnostic  technique  has  enabled  him  to  eliminate, 
to  begin  with,  organic  cases;  further  he  wo  aid  eliminate 
emotional  disorders  and  reflex  disorders,  leaving  a  more 
restricted  hysteria  to  which  he  has  applied  his  newly  coined 
term  pithiatism.  For  him  hysteria,  in  this  restricted 
sense,   consists  in  manifestations  which  are  brought  into 

1  W.  A.  White.  Current  Conceptions  of  Hysteria.  Interstate  Med. 
Journ.,  Jan.,  1910. 

"Babinski.  Demembrement  de  V hysteric  traditionelle.  Pithiatisme. 
Semaine  medicale,  Jan.  6,  1909. — Babinski  and  Froment.  Hysterie, 
pithiatisme  et  troubles  reflexes.     Paris,  1916. 


HYSTERIA  303 

existence  by  the  influence  of  suggestion  and  the  cure  of  which 
takes  place  by  persuasion;  the  characteristic  feature  of  the 
hysterical  personality  is  abnormal  suggestibility. 

Perhaps  the  most  significant  point  insisted  on  by  Babin- 
ski  is  the  necessity  for  distinguishing  true  hysteria  from  sim- 
ulation, especially  where  the  latter  manifests  itself  in  char- 
acteristically hysterical  phenomena — paralyses,  contractures, 
anaesthesia,  etc.  The  result  of  treatment  by  persuasion  here 
becomes  the  basis  of  the  differentiation:  if  persuasion  fails 
to  cure  the  case  is  not  hysteria  but  simulation. 

Heredity  and  Constitutional  Make-up. — Of  100  cases 
of  hysteria  observed  in  soldiers  in  the  U.  S.  Army  Hospital 
for  War  Neuroses  at  Plattsburg  Barracks,  N.  Y.,  there  was 
a  neuropathic  family  history  in  64,  a  negative  family  history 
as  regards  neuropathic  conditions  in  35,  and  data  unascer- 
tained in  the  remaining  case.  In  the  same  group  of  cases 
it  was  found  that  there  was  a  history  of  social  maladjust- 
ment in  some  form  prior  to  enlistment  in  51  cases,  a  negative 
history  as  regards  social  maladjustment  in  47  cases,  and  his- 
tory unascertained  in  2  cases.  As  evidences  of  neuropathic 
heredity  were  counted  cases  in  the  family  of  epilepsy,  fainting 
spells,  sick  headache,  insanity,  feeblemindedness,  alcoholism, 
criminalism,  eccentricities,  temperamental  anomalies,  ner- 
vous breakdown,  etc.  As  items  of  social  maladjustment 
were  counted  the  following  data  in  the  personal  history: 
poor  progress  in  school,  poor  showing  in  work,  intemper- 
ance, criminalism,  etc.  In  77  out  of  the  100  cases  there  was 
either  a  neuropathic  family  history,  or  a  history  of  social 
maladjustment  in  the  individual,  or  both.  Thus,  it  would 
seem  that  hysterical  phenomena  arise  on  a  basis  of  neuro- 
pathic constitution.^ 

Etiological  Factors  other  than  Heredity. — In  the  early 
months  of  the  war  medical  writers  mentioned  physical  and 
psychic   factors    in    the  etiology  of  hysteria  more  or  less 

^  A.  J.  Rosanoff.  A  Study  of  Hysteria  Based  Mainly  on  Material 
Observed  in  the  U.  S.  Army  Hospital  for  War  Neuroses  at  Plattsburg 
Barracks,  N.  Y.    Arch,  of  Neurol,  and  Psychiatry,  Oct.,  1919. 


304  -PSYCHONEUROSES 

indiscriminately.  Gradually,  as  the  distinction  became  clear 
between  true  cerebral  concussion  and  hysteria,  the  view 
gained  ground  that  physical  factors,  as  such,  played  no  part 
in  the  etiology  of  the  latter. 

In  studying  the  etiology  of  war  neuroses  it  would  seem 
important  to  distinguish  the  acute  emotional  disorders 
observed  at  the  front  from  hysteria.  This  distinction  has 
been  perhaps  most  clearly  drawn  by  Leri,  whose  experience 
extends  over  the  entire  duration  of  the  war  and  who,  in  that 
time,  had  opportunities  of  seeing  cases  at  the  front,  in  field 
hospitals,  and  in  neuro-psychiatric  centers  in  the  interior.^ 

Many  writers  have  shown  a  tendency  to  confound  emo- 
tional with  hysterical  disorders.  But  according  to  Leri  it  is 
a  mistake  to  think  that  hysterical  manifestations  are  an 
integral  and  necessary  part  of  the  emotional  syndrome. 
They  can  appear  independently  of  all  emotion;  and  the 
emotional  syndrome  has  nothing  in  common  with  hysteria. 

It  seems  that  the  psychic  factors  to  which  war  neuroses 
in  general  have  been,  attributed — fright  caused  by  danger 
from  projectiles,  horrifjdng  sights,  etc.,  play  a  part  only  in 
the  acute  emotional  syndrome;  hysterical  phenomena  are 
not  directly  produced  by  them. 

I  come  now  to  the  consideration  of  a  factor  which,  though 
seldom  frankly  avowed  by  patients  and  seldom  definitely 
established  by  clinical  investigation  in  individual  cases  of 
hysteria,  yet  has  made  itself  clearly  apparent  to  many 
observers  in  all  armies.  Speaking  for  myself  and  with  special 
reference  to  my  war  experience,  I  would  say  that  this  factor 
has  obtruded  itself  on  my  attention  until  I  have  come  to 
regard  it  as  the  mainspring  of  hysterical  conduct. 

This  factor  consists  in  a  concealed,  illicit,  morally  untenable 
motive. 

The  motive  is  not  always  the  same,  but  it  is  always  char- 
acterized by  the  above  mentioned  qualities.  Its  most  fre- 
quent variations  are:  (1)  To  evade  the  law  of  conscription. 
(2)  To  procure,  upon  reporting  for  physical  examination  at  a 

1  A.  Leri.     Commotions  et  Emotions  de  Guerre.     Paris,  1918. 


HYSTERIA  305 

training  camp,  rejection  for  physical  unfitness.  (3)  To 
evade  dangerous,  disagreeable,  or  difficult  duty,  or  to  evade 
all  duty.  (4)  To  procure  the  ease  and  privileges  of  hospital 
care.  (5)  To  procure  discharge  on  certificate  of  disability. 
(6)  To  procure  compensation  for  disability. 

That  illicit  motive  and  it  alone,  and  not  shell  concussion, 
war  strain,  emotional  shock,  etc.,  is  the  factor  which  actuates 
hysterical  conduct  is  further  shown  by  three  groups  of  facts 
of  the  highest  significance. 

In  the  first  place  are  to  be  mentioned  the  cases  of  hysteria 
arising  in  the  domestic  training  camps,  i.e.,  thousands  of  miles 
from  the  seat  of  war.  In  every  National  Army  cantonment 
cases  came  to  light  often  on  the  day  of  reporting  for  military 
duty,  more  often  early  in  the  course  of  training — at  any  rate 
before  any  "  war  strain  "  could  possibly  have  made  itself 
felt.  These  cases  presented  all  the  manifestations  of  hysteria 
which,  when  seen  in  overseas  cases,  have  so  often  been  attrib- 
uted to  "  shell  shock." 

In  the  second  place  is  the  striking  fact  that  among  prison- 
ers of  war  who  have  been,  like  other  soldiers,  exposed  to 
shell  fire,  strain,  etc.,  scarcely  any  cases  of  hysteria  or  other 
psychoneuroses  have  been  observed.^ 

In  the  third  place  is  the  very  common  experience  of  quick 
and  complete  recovery  from  hysterical  symptoms  upon  evacu- 
ation to  a  base  hospital,  followed  by  a  return  of  the  symptoms 
in  the  same  or  even  a  greater  degree  of  intensity  or  by 
development  of  new  symptoms  upon  any  prospect  arising 
of  being  sent  again  to  duty.  Many  of  the  overseas  cases 
have  furnished  such  a  history.  The  relapse  has  generally 
occurred  either  on  the  way  from  the  hospital  to  a  re-classi- 
fication camp  or  shortly  upon  arrival  at  such  a  camp.  Some- 
times no  cause  is  given  for  the  relapse,  at  other  times  a  trivial 
cause. 

1 F.  Lust.  Kriegsneurosen  und  Kriegsgefangene.  Miinch.  med. 
Woch.,  Dec.  26,  1916.  Abstracted  in  Journ.  Am.  Med.  Assn.,  Feb.  24, 
1917. — R.  Gaupp.  Discussion  of  War  Neuroses,  cited  in  Berlin  Letter. 
Journ.  Am.  Med.  Assn.,  Feb.  24,  1917. 


306  '  PSYCHONEUROSP]S 

Psychic  Mechanisms  underlying  Cures. — The  viewpoint 
advanced  here  with  reference  to  the  mechanism  of  hysteria 
is  borne  out  not  only  by  the  conditions  under  which  the 
disabling  symptoms  arise,  but  also  by  the  conditions  under 
which  they  disappear.  Various  methods  of  cure  have  been 
in  vogue  and  all  have  their  advocates  and  opponents:  rest, 
work,  massage,  electricity,  chloroform  ansesthesia  (for 
deaf -mutism),  hypnotism,  vocal  exercises,  psychoanalysis, 
etc. 

I  am  able  to  report  from  my  own  experience  that  the  par- 
ticular method  of  therapy  is  a  matter  of  comparatively  little 
importance  in  the  cure  of  hysterical  manifestations.  The 
mechanism  of  cure  readily  reveals  itself  when  studied  in  the 
light  of  the  above  discussed  mechanism  of  etiology.  One 
or  more  of  the  following  factors  are  frequently  seen  to  be 
operative  in  cures:  (1)  An  attitude  on  the  part  of  medical 
officers  impressing  patients  in  such  a  way  as  to  preclude 
any  hope  of  successful  imposition.  (2)  Demonstration  of 
the  unreal  nature  of  the  disability.  (3)  Strict  discipline  as 
opposed  to  sympathy,  coddling,  or  humoring.  (4)  Painful 
or  otherwise  disagreeable  features  of  treatment.  (5)  Re- 
moval of  motive,  actuating  the  symptoms,  by  change  in 
situation.  These  factors  deserve  somewhat  detailed  dis- 
cussion. 

The  first  mentioned  factor  is  all  important  for  the  pre- 
vention of  hysterical  manifestations  and  for  their  suppression 
in  the  earliest  stages.  ''  In  the  army  in  which  we  had 
the  direction  of  the  neurological  center  we  have  had  the 
satisfaction  of  seeing  the  number  of  '  nervous  seizures  ' 
diminish  from  the  time  the  rumor  was  spread — through 
soldiers  who  had  returned  to  their  organizations  without 
permission — that  with  us  '  the  seizures  were  not  in  good 
repute  and  were  regarded  rather  with  disfavor.'  As  to 
mutism  and  deaf -mutism,  we  have  seen  them  arise  in  certain 
armies  in  the  form  of  veritable  little  epidemics,  whereas  in 
others  they  were  almost  unknown."  ^ 

^  A.  L6ri.     Commotions  et  Emotions  de  Guerre.     Paris,  1918. 


HYSTERIA  307 

As  to  the  second  factor — demonstration  of  the  unreal 
nature  of  the  disabihty — it  is  plainly  operative  in  the  cures 
of  aphonia  and  mutism  by  means  of  general  anaesthesia 
and  of  paralyses  by  means  of  strong  electrical  stimulation. 
Patients  dread  being  detected  in  the  act  of  simulation  and 
therefore  yield  to  "  the  treatment  "  rather  than  allow  it  to 
appear  too  clearly  that  they  are  able  to  phonate,  talk,  or 
move  their  limbs  and  yet  will  not  do  so.  "  The  administra- 
tion of  ether  for  the  cure  of  functional  deafness  and  func- 
tional loss  of  voice  has  always  in  our  hands  proved  satisfac- 
tory. It  is  essential  that  the  loss  of  consciousness  be  slight, 
and  that  the  patient  be  suddenly  roused  so  as  to  realize  that 
he  is  speaking  or  hearing."  ^  The  principle  involved  in  the 
cure  of  paralyses  and  anesthesias  by  electricity  likewise  con- 
sists in  surprising  or  forcing  the  patient  into  betraying  by 
an  involuntary  movement  the  functional  integrity  of  both 
motion  and  sensation. 

The  third  factor — strict  discipline — is  unanimously  in- 
sisted on  by  all  who  have  had  cases  of  war  hysteria  to  treat, 
although  they  have  so  widely  disagreed  on  other  points. 

The  fourth  factor — painful  or  otherwise  disagreeable 
features  of  treatment — very  often  succeeds  where  others  have 
failed.  "  Prof.  Otto  Schultze  (Miinch.  med.  Woch.,  Sept. 
19,  1916),  who  published  a  review  of  the  reception  the 
Kaufmann  system  (painful  electric  shocks)  has  been  given 
by  the  medical  profession  in  Germany,  admits  that  it  has 
been  stigmatized  as  inhuman,  although  it  does  not,  he 
thinks,  inflict  pain  very  different  from  that  which  a  woman 
in  labor  suffers.  At  his  nerve  hospital  he  found  the  ordinary 
methods  of  treating  hysterical  motor  disturbances  unsatis- 
factory, whereas  the  adoption  of  Kaufmann's  system  led 
to  far  better  results.  Before  practicing  the  Kaufmann 
system  he  relied  mainly  on  the  peaceful  atmosphere  of  his 
mountain  hospital,  on  good  food,  rest  in  bed,  kindly  treat- 
ment, the  ignoring  of  symptoms,  and  the  use  of  sedatives 

^  A.  N.  Bruce.  The  Treatment  of  Functional  Blindness  and  Func- 
tional Loss  of  Voice.     Rev.  of  Neurol,  and  Psychiatry,  May,  1916. 


308  PSYCHONEUROSES 

and  hypnotics.  In  54  cases  thus  treated  marked  improve- 
ment or  recovery  was  obtained  in  4  only;  but  out  of  15 
patients  treated  on  Kaufmann's  hues  13  benefited  appre- 
ciably." 1 

The  fifth  factor — that  of  removal  of  motive,  actuating 
the  symptoms,  by  change  in  situation — is  the  most  effective 
and  theoretically  the  most  significant  one.  The  cases  which 
were  sent  to  the  Plattsburg  hospital  from  overseas  were 
for  the  most  part  those  which  had  proved  most  refractory 
to  treatment  in  hospitals  in  France.  Yet  a  great  many  of 
them  had  recovered  spontaneously  at  the  time  they  reached 
Plattsburg;  and  there  was  an  outbreak  of  spontaneous 
cures  following  the  signing  of  the  armistice.  This  experience 
is  analogous  to  the  peace-time  traumatic  hysteria.  "  The 
hysteria  observed  in  litigants  is  provoked  not  by  trauma,  not 
by  fright,  but  is  the  direct  result  of  the  psychology  of  com- 
pensation; namely,  of  the  recognition  by  the  plaintiff  that 
the  success  of  his  claim  for  compensation  depends  upon  the 
existence  and  persistence  of  symptoms.  For  this  reason 
treatment,  no  matter  of  what  character,  is  without  avail. 
The  plaintiff  neither  gets  well  nor  improves,  and  this  situa- 
tion may  continue  indefinitely,  sometimes  for  years;  indeed 
so  long  as  any  hope  of  settlement  persists  in  the  plaintiff's 
mind.  However,  all  medical  attendance  ceases  with  settle- 
ment. The  symptoms  disappear,  the  plaintiff  forgetting 
all  about  them.  The  immediate  absence  of  the  plaintiff 
from  physicians'  offices  and  hospital  clinics,  the  moment  the 
money  has  been  paid  him,  is  one  of  the  notorious  and  strik- 
ing facts  of  compensation  hysteria."  ^ 

Relationship  between  Hysteria  and  Malingering. — This 
brings  us  to  the  question  of  the  relationship  between  hysteria 
and  malingering.  Opinions  differ  as  to  when  a  diagnosis  of 
hysteria  should  be  made  and  when  one  of  malingering  would 

1  Disciplinary  Treatment  of  Shell  Shock.  (Notes  from  German  and 
Austrian  Journals.)     Brit.  Med.  Journ.,  Dec.  23,  1916. 

2  F.  X.  Dercum.  Rest,  Suggestion  in  Nervous  and  Mental  Diseases. 
Philadelphia,  1917. 


HYSTERIA  309 

be  justified.  Yet  even  those  who  hold  opposite  views 
are  agreed  as  to  there  being  a  close  similarity  in  the  clinical 
manifestations  of  the  two  conditions  and  as  to  there  being 
great  difficulty  in  establishing  the  differentiation  in  practice. 
"  Nothing,  it  may  be  said,  resembles  malingering  more  than 
hysteria ;  nothing  hysteria  more  than  malingering.  In  both 
alike  we  are  confronted  with  the  same  discrepancy — between 
fact  and  statement,  between  objective  sign  and  subjective 
symptom — the  outward  aspect  of  health,  seemingly  giving 
the  lie  to  all  the  alleged  functional  disabilities.  .  .  .  We  may 
examine  a  hysterical  person  and  a  malingerer — using  exactly 
the  same  tests — and  get  precisely  the  same  results  in  one  case 
as  in  the  other.  The  finer  the  methods  that  we  employ  to 
test  the  genuineness  of  their  complaints,  the  reality  of  their 
objective  phenomena,  the  more  do  they — in  hysterical 
individuals — yield  results  which  in  a  non-hysterical  person 
would  be  held  as  proof  of  positive  deceit.  In  short,  anyone 
who  has  had  much  experience  of  hysteria  comes  inevitably 
to  the  following  conclusion:  tests  for  malingering  holding 
valid  with  reference  to  organic  diseases  are  invalid  in  refer- 
ence to  hysteria."  ^ 

The  motives  enumerated  above  as  constituting  the  main- 
spring of  hysterical  conduct  are  the  same  as  those  which 
students  of  malingering  have  uniformly  reported  as  actua- 
ting their  cases.^  Also  the  manifestations  described  by 
students  of  malingering  are  exactly  the  same  as  those 
observed  daily  in  hysteria.  Jones  and  Llewellyn,  for 
instance,  describe  the  following:  pain,  hypersesthesia,  anaes- 
thesia, analgesia,  limping  gait,  tremor,  contractures,  paral- 
ysis, epileptiform  seizures,  amaurosis  or  amblyopia,  contrac- 
tions of  the  visual  field,  deafness,  aphonia,  stuttering,  mutism, 
deaf-mutism,  etc. 

A  search  through  the  literature  reveals  but  one  point  to 

1  A.  B.  Jones  and  L.  J.  Llewellyn.  Malingering.  Philadelphia, 
1918. 

^  Pearce  Bailey.  Malingering  in  U.  S.  Troops.  The  MiUtary  Sur- 
geon, March  and  April,  1918. — Jones  and  Llewellyn.     Loc.  cit. 


310  '  PSYCIIONEUROSES 

which  the  differentiation  is  fastened  almost  unanimously, 
namely,  the  conscious  or  unconscious  quality  of  the  motivation. 
Yet  even  on  this  point  writers  have  shown  much  inconsist- 
ency ;  for  it  is  admitted  that  malingering,  as  well  as  hysteria, 
may  be  subconscious  or  unconscious.^  But  there  is  more  to 
add  to  the  confusion.  A  case,  it  is  said,  may  begin  with  con- 
scious deception  and  end  with  unconscious  self-deception; 
or  vice  versa;  or  there  may  be  a  mixture  of  unconscious  and 
conscious  simulation,  i.e.,  hysteria  complicated  with  maling- 
ering; or  there  may  be  a  condition  half-way  between 
conscious  and  unconscious  simulation  .^ 

It  is  strange  that  so  futile  a  consideration,  one  so  obviously 
belonging  to  the  domain  of  metaphysics  and  not  science,  as 
the  question  of  degree  of  consciousness  of  a  mental  process, 
should  become  the  preoccupation  of  scientific  men  and 
should  be  chosen  as  a  criterion  of  chnical  diagnosis!  When 
we  are  dealing  with  weak-minded,  emotionally  unstable, 
moralty  defective  individuals,  such  as  hysterics  and  maling- 
erers are;  and  when,  moreover,  the  question  is  one  of  "con- 
scious "  or  "  unconscious "  deception,  it  is  all  the  more 
amazing  that  a  criterion,  which  is,  in  the  first  place,  vague, 
and,  in  the  second  place,  purely  subjective,  should  seriously 
occupy  the  professional  mind  as  a  guide  in  practical  work. 

Among  other  points  of  differentiation  between  hysteria 
and  malingering  which  have  been  suggested  are:  (1)  Results 
of  treatment  b}^  persuasion,  i.e.,  if  persuasion  fails  to  cure  the 
case  is  not  hj^steria  but  malingering  (Babinski).  (2)  A 
desire  to  be  cured  speaks  for  hysteria;  the  opposite  indicates 
mahngering.  (3)  The  malingerer  dreads  examination; 
the    hysteric    welcomes    it.     (4)  Hysterical   manifestations 

1 B.  Glueck.  The  Malingerer;  a  Clinical  Study.  International 
Clinics,  Vol.  Ill,  Series  25,  1915. — R.  Sheehan.  Malingering  in  Mental 
Disease.     U.  S.  Naval  Med.  Bull.,  Oct.,  1916. 

2  H.  Campbell.  War  Neuroses.  Practitioner,  May,  1916. — W. 
Harris.  Nerve  Injuries  and  Shock.  (Oxford  War  Primers.)  London, 
1915. — A.  B.  Jones  and  L.  J.  Llewellyn.  Malingering.  Philadelphia, 
1918. — Pearce  Bailey.  Malingering  in  U.  S.  Troops.  The  Military 
Surgeon,  Mar.  and  Apr.,  1918. 


HYSTERIA  311 

bear  the  stamp  of  a  certain  genuineness  which  those  of 
mahngering  lack.  These  points  merit  somewhat  detailed 
discussion. 

As  regards  results  of  treatment  by  persuasion,  it  is  very 
generally  recognized  that  in  many  cases  which  are  by  all 
diagnosed  as  typical  hysteria  persuasion  fails  to  cure — 
so-called  refractory  hysterics.  In  other  cases,  also  refractory, 
a  cure  is,  indeed,  obtained  by  persuasion,  but  only  when  it  is 
reinforced  with  painful  electrical  treatment  (Kaufmann 
method),  isolation  on  liquid  diet,  threat  of  operation  or  of 
court  martial,  etc. 

It  is  true,  of  course,  that  many  cases  of  hysteria  have 
readily  yielded  to  persuasion;  but  the  conditions  under 
which  that  has  happened  should  be  taken  into  account. 
When  the  danger  was  removed  of  being  returned  to  the  front, 
especially,  as  already  stated,  after  the  signing  of  the  armis- 
tice, many  cases  were  not  only  easily  "  persuaded,"  but  were 
cured  by  any  method  that  happened  to  be  tried,  though 
they  had  previously  proved  refractory.  The  cure  in  these 
cases  is  obviously  to  be  attributed  not  so  much  to  persuasion 
as  to  the  removal  of  the  danger,  the  presence  of  which  had 
given  rise  to  the  symptoms.  Some  cases  have  remained 
refractory  even  since  the  signing  of  the  armistice;  in  these 
cases  the  actuating  motive  is  to  gain  government  compen- 
sation; that  is  the  reason  why  the  "  persuasion  "  that  has 
cured  thousands  of  others  is  doing  them  no  good. 

Moreover,  proved  malingering  has  also  in  many  cases 
yielded  to  persuasion,  while  other  cases  have  proved  refrac- 
tory; in  other  words,  the  experience  with  malingering,  in 
that  respect,  has  been  exactly  like  the  experience  with 
hysteria.  Of  great  interest  in  this  connection  are  the 
observations  of  Sicard.^ 

Babinski's  differentiating  test  of  cure  by  persuasion  is 

^  J.  A.  Sicard.  Simulateurs  sourds-muets.  Paris  med.,  Oct.  23, 
1915.  Abstracted  in  English  by  M.  W.  Brown  and  F.  E.  Williams, 
in  N euro-Psychiatry  and  the  War,  published  by  The  National  Com- 
mittee for  Mental  Hygiene,  New  York,  1918. 


312  PSYCHONEUROSES 

based  on  his  general  conception,  according  to  which  the  essen- 
tial feature  of  the  hysterical  personality  is  abnormal  sug- 
gestibility. But  a  close  scrutiny  of  the  facts  does  not  support 
this  conception.  An  equally  plausible  case  might  be  made 
out  for  abnormal  lack  of  suggestibility. 

Under  certain  conditions  the  hysteric  is,  indeed,  remark- 
ably receptive  to  certain  suggestions;  he  is  at  the  same  time 
refractory  to  others.  When  he  has  to  play  sick  in  order  to 
avoid  dangerous  duty  he  will  not  only  be  readily  influenced 
by  suggestions  unwittingly  made  by  the  examining  physician 
in  testing  for  disorders  of  sensation,  etc.,  but  will  actually 
seek  suggestions  by  observing  cases  of  real  disease  and  will 
develop  by  auto-suggestion  such  symptoms  as  he  may  imagine 
to  be  appropriate  for  a  "  dead  nerve,"  "  stoppage  of  circula- 
tion," etc.  At  the  same  time  he  is  apt  to  resist  any  sug- 
gestion of  cure. 

But  a  time  comes,  when,  upon  removal  of  danger,  the 
situation  changes.  What  was  previously  a  life-saving  dis- 
ability now  becomes  a  nuisance.  Although  many  are, 
in  the  new  situation,  cured  spontaneously,  others  feel  that  a 
sudden  cure  without  treatment  would  but  betray  the  false 
nature  of  the  trouble.  Nothing  is  more  natural  than  that 
they  should  again  seek  the  cooperation  of  the  medical  pro- 
fession to  assist  them  in  making  a  seemly  and  plausible 
exit  from  an  awkward  situation.  And  so,  after  taking 
electricity,  hypnosis,  re-education,  vocal  exercises,  or  what 
not,  accompanied  by  "  suggestion,"  they  are  pronounced 
cured:  this  carries  with  it  not  only  relief  from  a  no  longer 
serviceable  disability,  such  as  mutism,  paralysis,  contracture, 
etc.,  but  also,  by  implication,  added  certification  by  duly 
constituted  medical  authority  that  a  disease  had  existed. 

Turning  now  to  the  next  point  of  differentiation,  accord- 
ing to  which  a  desire  to  be  cured  speaks  for  hysteria,  while 
the  opposite  indicates  malingering,  I  am  forced  to  judge 
from  the  war  experience  that  no  such  generalization  is  pos- 
sible; in  a  given  case  everything  depends  on  special  cir- 
cumstances.    This  is,  in  fact,  the  view  held  by  many  com- 


HYSTERIA  313 

petent  students  of  hysteria:  "  Every  practitioner  knows  the 
service  a  nervous  illness  often  is  to  a  patient  in  dealing  with 
relatives,  over  whose  head  the  patient  holds  it  almost  as  a 
threat;  this  process  may  be  consciously  or  unconsciously 
carried  out.  Under  such  circumstances  the  patient's  deep- 
rooted  objection  to  getting  better  may  defy  all  therapeutic 
measures."  ^  I  have  seen  cases  in  which  stubborn  resistance 
to  treatment  gave  way,  following  the  signing  of  the  armistice, 
to  an  impatient  longing  to  get  well. 

The  next  alleged  differentiating  point,  according  to  which 
the  malingerer  dreads  examination,  while  the  hysteric  wel- 
comes it,  is,  as  far  as  my  experience  is  concerned,  also  un- 
trustworthy. In  the  one  case  of  proved  malingering  observed 
by  me,  in  which  conviction  and  sentence  by  general  court 
martial  was  obtained,  the  patient  willingly  at  all  times 
reiterated  his  story,  gave  written  statements,  submitted  to 
neurological  examinations  in  which  the  areas  of  anaesthesia 
were  repeatedly  mapped  out,  etc.  He  was,  of  course,  not 
told  that  these  examinations  had  for  their  object  the  dstec- 
tion  of  simulation.  Under  similar  conditions  hysterics,  too, 
welcome  examination.  But  I  have  many  times  seen  hysterics 
cease  to  cooperate  and  become  resistive  to  examination  upon 
a  suspicion  arising  in  their  minds  that  the  object  of  the  exami- 
nation was  to  test  the  genuineness  of  the  symptoms.  This 
was  especially  noted  in  cases  of  convulsions,  in  which  patients 
by  turning  away,  biting,  struggling,  and  fighting  resisted  an 
examination  of  the  pupils,  knee  jerks,  plantar  reflexes,  etc. 

The  last  above  mentioned  differentiating  point,  according 
to  which  hysterical  manifestations  bear  the  stamp  of  a  certain 
genuineness  which  those  of  malingering  lack,  is  also  not  to 
be  relied  on.  All  that  can  be  said  is  that  in  both  hysteria 
and  malingering  one  meets  with  various  degrees  of  adroit- 
ness in  simulation,  various  degrees  of  determination  and  per- 
sistence. "  Macdonald  tells  of  a  man,  feigning  epilepsy, 
who  during  a  fit  suffered  without  flinching  knives  thrust 
under  his  nails,  the  insufflation  of  irritating  powders  into  his 
^  E.  Jones.     Papers  on  Psycho-Analysis.     London,  1918. 


314  PSYCHONEUROSES 

eyes,  and  one  day  fell  30  feet  to  convince  the  expert,  though 
finally  he  acknowledged  his  deceit."  ^ 

To  sum  up:  My  own  experience,  much  discussion  with 
other  medical  officers,  and  a  study  of  the  literature,  all  lead 
me  to  the  conclusion  that  what  some  have  described  under  the 
name  of  hysteria  and  what  others  have  described  under  the  name 
of  malingering  are  one  and  the  same  thing.  The  difference 
seems  to  be  entirely  one  of  viewpoint.  Hysteria  is  an 
expression  which  would  stress  a  medical  viewpoint.  Maling- 
ering is  one  which  would  stress  a  legal  viewpoint. 

Sex  Factors. — Intrapsychic  Conflicts. — There  remain 
two  other  points  in  connection  with  hysteria  which  merit 
discussion  in  the  light  of  the  war  experiences:  (1)  the  part 
played  by  sex  factors,  (2)  the  theory  of  intrapsychic  con- 
flicts. Both  these  points,  as  all  know,  have  been  stressed 
by  Freud  and  others  of  his  school. 

Although  Freud's  views  as  to  the  exact  part  played  by 
sex  factors  in  hysteria  have  undergone  considerable  modifica- 
tion from  the  time  of  his  original  formulation  nearly  twenty- 
five  years  ago,  yet  even  in  his  more  recent  formulations  the 
sex  element  is  regarded  as  essential  in  the  etiological  mechan- 
ism of  hysteria:  "  The  hysterical  symptom  corresponds  to  a 
return  to  a  manner  of  sexual  gratification  which  was  real  in 
infantile  life  and  which  has  since  been  repressed." — "  The 
hysterical  symptom  can  assume  the  representation  of  various 
unconscious  non-sexual  impulses  but  cannot  dispense  with  a 
sexual  significance."  ^ 

It  seems  quite  probable  that,  in  relation  to  a  certain 
variety  of  clinical  material — especially  such  as  would  be 
most  likely,  in  times  of  peace,  to  come  to  the  attention  of  a 
nerve  specialist  devoted,  like  Freud,  to  psychoanalytic 
practice — the  idea  of  the  universality  of  sex  factors  is  well 

1  A.  B.  Jones  and  L.  J.  Llewellyn.  Malingering.  Philadelphia, 
1918. 

2  S.  Freud.  Sammlung  kleiner  Schriften  zur  Neurosenlehre.  Zweite 
Folge,  1909.  Quoted  by  O.  Pfister.  The  Psychoanalytic  Method. 
English  translation  by  C.  R.  Payne,  New  York,  1917. 


HYSTERIA  315 

founded.  The  sphere  of  sex,  under  ordinary  conditions, 
might  even  a  priori  be  regarded  as  the  main  if  not  the  sole 
source  of  "  concealed,  illicit,  morally  untenable  motives  " 
postulated  by  me  as  the  mainspring  of  hysterical  conduct. 
But  the  war  experience  has  shown  even  to  loyal  adherents 
of  Freud  that  hysterical  manifestations  can  be  actuated  by 
motives  other  than  sexual.  In  medico-legal  practice,  even 
in  peace  times,  neurologists  have  seen  but  too  often  hyster- 
ical manifestations  ("  traumatic  neuroses  ")  arise  on  the 
basis  of  exaggerated  claims  for  indemnity,  sick  benefit, 
accident  insurance,  workmen's  compensation,  etc.,  without 
the  intervention  of  sex  motives. 

It  seems,  therefore,  justifiable  to  conclude  that  an  illicit 
motive  is  an  essential  part  of  the  mental  mechanism  of  hys- 
teria; but  such  motive  need  not  be  of  a  sexual  nature,  al- 
though undoubtedly  it  very  often  is. 

Turning  now  to  the  subject  of  intrapsychic  conflicts,  it 
will  be  remembered  that  the  manifestations  of  hysteria  are 
regarded  by  some  as  a  sort  of  compromise  resulting  from  a 
conflict  between  repressed,  subconscious  wishes  and  the 
patient's  conscious  tendencies  representing  the  better  part 
of  his  "  split-up  personality." 

I  can  confirm,  from  such  observations  as  I  have  been  able 
to  make,  the  existence  of  a  conflict.  But  it  has  seemed  to  me 
to  be,  for  the  most  part  if  not  entirely,  a  conflict  rather  be- 
tween the  patient's  desire  to  shirk,  loaf,  avoid  exposure  to 
danger,  gain  unearned  compensation,  etc.,  and  pressure  from 
external  sources  the  object  of  which  might  be  to  expose  his 
motives  and  the  unreal  nature  of  his  disability,  to  bring  on 
him  the  opprobrium  of  his  comrades,  to  render  him  liable  to 
legal  prosecution,  etc.  In  other  words,  I  was  unable,  in  the 
great  majority  of  cases,  to  detect  any  pricking  of  conscience, 
evidences  of  regret  at  being  a  burden  rather  than  a  help  to 
their  country  in  ite  great  emergency,  any  struggle  between  a 
nobler  and  baser  parts  of  self,  but  rather  lack  of  evidence 
of  the  existence  of  a  nobler  self  in  these  cases. 

This  brings  us  to  the  subject  of  the  hysterical  personality. 


316  PSYCHONEUROSES 

The  Hysterical  Personality. — The  family  and  personal 

histories  of  hysterics  indicate  some  sort  of  relationship  to 
the  constitutional  psychoses,  epilepsy,  mental  deficiency, 
constitutional  psychopathic  states,  etc.  But  the  hysterical 
personality  can  be  more  specifically  defined.  Its  essential 
feature,  it  seems  to  me,  consists  in  a  character  defect,  which 
I  shall  now  take  pains  to  describe. 

Perhaps  it  is  worth  while  to  point  out,  to  begin  with, 
that  in  the  moral  side  of  our  nature  three  motivating  prin- 
ciples can  be  distinguished,  each  of  which  actuates  our 
conduct  in  a  measure  which  differs  in  different  individuals. 

The  first  of  these  may  be  termed  pitre  or  cesthetic  morality; 
it  is  represented  in  the  saying,  "  It  is  better  to  be  right  than 
to  be  president."  No  considerations  of  selfish  advantage, 
of  mere  catering  to  popular  taste  or  demand  or  to  the  powers 
that  be,  are  here  permitted  to  enter.  A  person  actuated  by 
this  principle  turns  away  from  thoughts  of  deception,  theft, 
dishonesty,  or  any  other  moral  filth,  just  as  he  might,  from 
inherent  aesthetic  repulsion,  turn  away  from  a  foul  smell. 

The  second  principle  may  be  termed  prudent  morality; 
it  is  represented  in  the  saying  "  Honesty  is  the  best  policy." 
Unlike  the  case  of  the  first  principle,  here  considerations  of 
selfishness  and  personal  ambition  not  only  are  permitted  to 
enter  but  are  the  basis  of  doctrine.  A  person  actuated  by 
this  principle  turns  away  from  wrongdoing  not  from  an 
aesthetic  aversion,  but  because  of  a  conviction  that,  in  the 
long  run  at  least,  it  does  not  pay. 

The  third  principle,  imposed  morality,  has  its  roots  in  the 
deterrent  force  of  such  measures  of  redress,  retaliation,  or 
protection  as  are  available  to  individuals  and  society  in 
deaUngs  with  wrongdoers.  A  person  actuated  by  this  prin- 
ciple has  no  aesthetic  aversion  to  wrongdoing ;  and  he  regards 
the  maxim  of  prudence  with  cynicism.  His  preoccupation 
is  mainly  how  to  escape  detection,  conviction,  and  punish- 
ment. If  he  refrains  from  wrongdoing,  it  is  only  when  the 
risk  involved  is  too  great  and  too  immediate. 

I  could  not  better  define  the  hysterical  personaHty,  as  I 


HYSTERIA  317 

have  observed  it,  than  by  saying  that  it  is  characterized  by 
total  lack  of  the  first  principle — pure  or  aesthetic  morahty; 
that  it  is  at  best  actuated  by  the  second  principle — prudent 
morality;  and  that  it  is,  in  its  typical  manifestations, 
actuated  entirely  by  the  third  principle — imposed  morality, 
i.e.,  in  so  far  as  its  conduct  has  any  moral  quality  at  all. 

This  places  the  hysterical  individual  in  close  relation 
to  the  criminal.  Therein  I  believe  my  conception  to  be 
correct.  Yet  a  certain  difference  may  be  pointed  out. 
Most  hysterics  are  characterized  by  a  trait  which  is  foreign 
to  many  crhninals:  indolence. 

A  desu'e  to  lead  a  parasitic  existence,  to  be  a  burden  on 
relatives,  employers,  the  government,  to  hve  on  a  pension 
and  do  no  work,  is  characteristic  of  many  of  these  patients. 
They  would,  and  often  do,  steal  anything  conveniently 
within  reach,  lie,  cheat,  make  work  and  trouble  for  others, 
wantonly  destroy  government  property,  but  they  have  not 
the  enterprise  or  energy  that  some  criminals  have  of  planning 
and  carrjdng  out  an  embezzlement,  or  a  burglary,  or  a  train 
robbery:  that  is  too  much  like  work. 

This  description  may  seem  to  some  much  overdrawn. 
I  would,  therefore,  at  this  point  again  call  attention  to  the 
fact  that  the  above  described  traits  of  hysterical  personality 
exist  in  all  degrees.  Between  the  man  of  highest  integrity 
actuated  only  by  the  purest  motives  of  unselfish  service, 
and  the  one  who  utterly  lacks  all  moral  compunction  and  is 
constantly  preoccupied  with  motives  of  shirking  and  of 
organizing  a  parasitic  existence,  there  are  many  shades  of 
transition. 

It  should,  moreover,  be  borne  in  mind  that  the  material 
observed  in  the  Plattsburg  hospital,  on  which  in  the  main 
this  account  is  based,  represents,  by  selection,  the  most 
refractory  cases  of  hysteria  met  with  in  the  army, 


318     •  PSYCHONEUROSES 

§  2.     Neurasthenia 

The  cases  classed  under  the  heading  of  neurasthenia 
may  be  roughly  divided  into  four  groups  which  are  super- 
ficially very  similar  to  each  other  but  which,  on  closer  study, 
may  be  found  to  be  based  on  wholly  different  psychic 
mechanisms:  (1)  hystero-neurasthenia,  (2)  splanchnic  neu- 
rasthenia, (3)  sexual  neurasthenia,  (4)  neurasthenic  state 
allied  to  manic-depressive  psychoses. 

Hystero-neurasthenia  is  characterized  by  vague  general 
hypochondriasis  with  purely  subjective  symptoms,  without 
organic  basis,  and  may  often  be  shown  to  be  motivated 
exactly  in  the  manner  of  the  above  discussed  hysterical  mani- 
festations. It  is,  to  my  mind,  but  a  special  type  of  hysteria 
or  simulated  disease.  It  is  apt  to  be  seen  in  individuals 
presenting  the  same  sort  of  character  defect  as  that  which 
underlies  common  hysteria,  but  better  endowed  in  intelligence 
and  education,  more  polished  and  diplomatic,  more  subtle  and 
plausible.  Thus,  during  the  World  War,  all  observers  have 
noted  that  this  condition  is  relatively  more  frequent  in  com- 
missioned officers  than  enlisted  men.  My  experience  has 
amply  shown  that  the  possession  of  intelligence  far  above  the 
average  and  good  educational  and  social  opportunities  is 
xiot  incompatible  with  gross  lack  in  moral  sentiment. 

Splanchnic  neurasthenia  is  characterized  physically  by 
general  undernutrition,  muscular  atony,  lack  of  endurance, 
tendency  to  become  giddy  and  faint,  rather  light  and  restless 
sleep  at  night,  perhaps  troubled  with  muscular  twitchings 
and  jerkings,  somnolence  during  the  day,  frequent  headaches, 
and  various  abdominal  symptoms  referable  to  visceroptosis 
which  is  usually  present  in  more  or  less  pronounced  degree: 
dull  pain  and  tenderness  in  hypochondriac  or  iliac  regions, 
poor  and  capricious  appetite,  frequent  nausea  and  vomiting, 
constipation,  "gas  pains,"  and  occasionally  signs  of  floating 
kidney  or  uterine  displacements.  Mentally  this  condition 
is  characterized  mainly  by  habitual  hypochondriasis,  i.e., 
preoccupation  with  bodily  symptoms,  disinclination  to  effort 


NEURASTHENIA  319 

or  exertion,  and  a  resulting  general  futility,  superficiality, 
and  inefiicienc3^ 

Sexual  neurasthenia  occurs  more  often  in  men  than  in 
women.  The  patients  commonly  complain  of  seminal  emis- 
sions, premature  orgasm  upon  attempts  of  intercourse, 
impotence;  they  are  filled  with  anxious  thoughts  of  "lost 
manhood"  which  they  would  attribute  to  masturbation  in 
youth.  They  allow  their  minds  to  dwell  almost  constantly 
on  their  sex  function,  are  self-absorbed  and  brooding,  often 
bashful  and  seclusive.  They  are  given  to  reading  quack 
literature  and  going  to  advertising  doctors.  Many  cases 
would  seem  to  be  mild  or  incipient  dementia  prsecox. 

Neurasthenic  states  allied  to  manic-depressive  psychoses 
are  popularly  known  as  "  nervous  prostration  "  or  "  nervous 
breakdown "  and  are  characterized  by  depression,  dis- 
couragement, difficulty  of  concentration,  feeling  of  inade- 
quacy, and  psychomotor  retardation.  Often  they  are 
accompanied  by  suicidal  tendency. 

§  3.       PSYCHASTHENIA 

Psychasthenia  is  characterized  by  obsessions,  morbid 
fears  and  doubts. 

An  obsession  ^  consists  in  an  imperative  idea  associated 
with  a  state  of  anxiety,  there  heiyig  no  marked  disorder  of  con- 
sciousness or  judgment. 

We  have  already  studied  imperative  ideas  and  learned 
that  they  constitute  a  form  of  mental  automatism. 

We  have  also  studied  the  principal  characteristics  of 
anxiety.  Its  relations  to  imperative  ideas  have  been  much 
discussed.  Westphal,  who  was  one  of  the  first  to  make  a 
thorough  study  of  obsessions,  is  of  the  opinion  that  the 
anxiety  is  always  secondary  to  the  imperative  idea.     This 

1  Arnaud.  Su  lar  theorie  de  V obsession.  Arch,  de  neurol.,  1902, 
No.  76. — Roubino witch.  Etude  clinique  des  obsessions  et  des  impul- 
sions morbides.  Ann.  med.  psych.,  Sept.-Oct.,  1899. — P.  Janet. 
Les  obsessions  et  Vanasthenie,  1902,  Paris,  F.  Alcan. 


320  PSYCHONEUROSES 

opinion  is  certainly  too  absolute,  for  anxiety  may  precede 
the  imperative  idea  and  even  appear  independently  of  it. 

Ribot,  Freud,  Pitres,  and  Regis  have  insisted  upon 
those  cases  of  diffuse  anxiety,  or  panophobia,  in  which 
the  emotion  exists  independently  of  any  fixed  idea.^ 

This  question  seems  to  be  analogous  to  that  which 
we  have  considered  in  connection  with  allopsychic  dis- 
orientation and  hallucinations.  We  are  inclined  in  this 
case  to  view  with  favor  a  similar  solution,  namely,  that 
imperative  ideas  and  anxiety  are  two  manifestations  of 
the  same  fundamental  psychic  disorder. 

Intact  consciousness  and  judgment  are,  as  we  have 
just  pointed  out,  the  rule  in  obsessions;  the  patient  is 
therefore  able  to  realize  the  pathological  nature  of  the 
phenomenon.  There  are,  however,  some  exceptions  to 
this.  The  subject  has  sometimes,  when  his  anxiety  reaches 
its  height,  a  sense  of  reduplication  or  of  transformation  of 
the  personality.  One  such  patient  of  Seglas'  entered  a 
shop  "  to  speak  to  the  clerks,  to  ask  for  something  and  thus 
to  find  new  proof  that  she  was  her  real  self." 

Obsessions  are  occasionally  accompanied  by  halluci- 
nations, chiefly  motor  hallucinations,  which  in  a  manner 
exteriorize  the  imperative  idea. 

Obsessions  are  of  various  forms.  First  of  all,  three 
great  classes  are  to  be  distinguished,  depending  upon  the 
influence  which  the  imperative  idea  exercises  upon  the 
patient:  (1)  intellectual  obsessions,  which  are  unaccompanied 
by  any  voluntary  activity;  (2)  impulsive  obsessions,  in 
which  the  idea  tends  to  be  transformed  into  an  act;  (3) 
inhibiting  obsessions,  the  action  of  which  tends  to  paralyze 
certain  voluntary  acts. 

(1)  Intellectual  Obsessions. — The  consciousness  of  the 
patient  is  occupied  either  by  some  concrete  idea — a  word, 

1  Freud.     Obsessions    et    phobies.     Rev.    neurol.,  1895. — Manaud. 

La    nevrose    d'angoisse.     Troubles    nerveux    d'origine  sexuelle.     These 

de  Lyon,  1900. — P.  Londe.  De  I'angoisse.  Rev.  de  med.,  1902, 
Aug.-Oct. 


PSYCHASTHENIA  321 

an  object,  an  image  of  some  person  or  of  some  scene — or 
by  some  abstract  idea,  often  of  a  metaphysical  nature. 
To  the  latter  category  belong  the  obsessions  in  which  the 
subject  has  a  feeling  that  he  does  not  exist,  that  the  external 
world  is  formed  of  nothing  but  phantoms,  etc.  The  im- 
perative idea  is  then  said  to  have  a  negative  form.  In 
other  instances,  without  going  as  far  as  complete 
negation,  it  is  expressed  by  doubt,  thus  constituting  a 
transitional  form  between  intellectual  and  inhibiting 
obsessions. 

(2)  Impulsive  Obsessions. — These  are  very  numerous. 
The  following  are  the  principal  forms : 

Onomatomania:  an  irresistible  desire  to  pronounce 
certain  words,  sometimes  obscene  words  (coprolalia). 

Arithmomania:  an  irresistible  desire  to  count  certain 
objects,  add  certain  figures,  etc. 

Kleptomania:  a  morbid  impulse  to  steal  objects  which 
are  entirely  useless,  or  which  the  subject  can  easily 
pay  for. 

Dipsomania:  an  irresistible  impulse  to  drink  alcoholic 
beverages  of  every  description  (wines,  liquors,  eau-de- 
Cologne,  spirits  of  camphor,  etc.),  occurring  in  a  person  of 
temperate  habits,  who  may  at  other  times  have  even  a  dis- 
like for  alcohol.  The  attacks  may  recur,  and  the  dipso- 
maniac may  become  an  alcoholic.  He  differs  radically  from 
the  ordinary  drunkard,  however.  "  The  one  is  alienated 
before  beginning  to  drink,  the  other  (the  alcoholic)  becomes 
alienated  because  of  his  drinking"  (Magnan). 

Pyromania;  Suicidal  and  Homicidal  Impulses:'^  These 
three  obsessions  are  of  equal  gravity  from  a  social  stand- 
point and  may  be  placed  in  the  same  group.  The  first 
consists  in  a  morbid  impulse  to  set  buildings  on  fire;  the 
other  two  require  no  definition. 

In  some  cases  the  patients  obey  their  fatal  impulses. 

^  Vallon.  Obsession  homicide.  Ann.  med.  psych.,  Jan.-Feb.,  1896. 
— Carrier.  Contribution  a  Vetude  des  obsessions  et  des  impulsions  d 
Vhomicide  et  au  suicide.     These  de  Paris,  1900. 


322  PSYCHONEUROSES 

Vallon  has  reported  a  case  of  a  young  man  who,  having 
a  homicidal  obsession,  struggled  against  the  impulse,  but 
was  finally  overcome  and  yielded. 

Such  cases,  however,  are  rare.  Usually  the  patients 
succeed  by  various,  and  at  times  singular,  means  in  resisting 
their  impulse.  Many  take  flight  at  the  moment  of  the 
paroxysm;  others  request  to  be  restrained  or  held;  still 
others  voluntarily  have  themselves  committed.  One  patient 
of  Joffroy's,  while  walking  in  the  street,  was  seized  with  the 
idea  of  throwing  her  child  under  the  wheels  of  a  passing 
car;  she  entered  a  wine  merchant's  shop,  placed  her  child 
upon  the  counter  and  took  flight. 

Similarly,  it  is  rare  for  patients  to  yield  to  a  suicidal 
impulse.  The  means  they  make  use  of  to  escape  their 
obsessions  are  innumerable.  A  woman  possessed  by  the 
idea  of  throwing  herself  out  of  the  window  had  all  the  win- 
dows of  her  house  protected  with  iron  bars.  Another 
such  unfortunate  condemned  herself  never  to  cross  the  Seine 
river  to  prevent  herself  from  yielding  to  the  impulse  to  drown 
herself. 

As  to  family  suicide,  it  is  almost  never  the  result  of  an 
obsession,  but  of  a  fixed  idea  which  is  developed  by  imitation. 

(3)  Inhibiting  Obsessions. — Like  the  preceding  ones, 
these  assume  very  varied  forms. 

One  of  the  most  frequent  is  "  doubting  mania."  Its 
characteristic  feature  is  the  inability  on  the  part  of  the 
patient  to  affirm  a  fact  or  to  make  a  decision. 

Many  normal  persons  experience  this  phenomenon 
in  a  slight  degree.  At  the-  borderland  of  doubting  mania 
we  find  individuals  who  hesitate  before  mailing  a  letter, 
in  spite  of  having  already  several  times  verified  the  contents, 
the  address,  the  sealing  of  the  envelope,  adherence  of  the 
stamp,  etc. 

Doubt  is  likely  to  assume  the  form  of  scruples,  so  fre- 
quent in  religious  persons:  a  fear  of  profaning  sacred  objects, 
of  not  being  in  a  holy  state  of  mind,  etc. 

Closely   related    to    doubting   mania   are    the    phobias, 


PSYCHASTHENIA  323 

which  are  usually  groundless  and  sometimes  ridiculous; 
their  absurdity  is  recognized  by  the  subject  himself. 

Some  patients  do  not  dare  to  touch  any  object,  con- 
stantly wear  gloves,  wash  their  hands  a  hundred  times 
daily,  etc.  This  phobia,  which  includes  also  the  fear  of 
contracting  an  infectious  disease  through  contact  with 
contaminated  articles  {nosophobia),  constitutes  "  delire  du 
toucher." 

Others  have  a  fear  of  being  unable  to  stand  up  or  to 
accomplish  certain  movements,  such  as  walking.  "  In 
a  deserted  place,  in  a  very  wide  street,  upon  a  bridge,  in  a 
church,  or  in  a  theatre  the  patient  is  suddenly  seized  with 
the  idea  that  he  will  be  unable  to  cross  the  wide  space 
before  him,  that  he  is  going  to  die,  or  that  he  is  going  to  be 
sick."  1 

This  morbid  phenomenon,  known  as  agoraphobia,  in- 
duces a  veritable  functional  paralysis,  and  the  patient  may 
fall  if  he  is  not  supported.  The  slightest  support  is  sufficient 
to  calm  and  reassure  him;  the  origin  of  the  attack  is,  there- 
fore, purely  psychic. 

Claustrophobia  is  the  opposite  of  agoraphobia;  it  con- 
sists of  an  inability  on  the  part  of  the  patient  to  remain  in 
a  closed  space. 

Erythrophobia,  first  described  by  Pitres  and  Regis,  con- 
sists in  a  fear  of  blushing.  These  patients  do  not  dare  to 
attract  anybody's  attention  to  themselves,  being  sure  to 
blush  most  distressingly.  This  phobia  is  closely  related 
to  ordinary  timidity,  of  which  it  is  occasionally  a  com- 
plication. 

The  following  case  shows  a  state  of  panophobia  or 
diffuse  anxiety  combined  with  very  pronounced  doubting 
mania,  manifesting  itself  by  constant  uncertainty  and  by 
moral  and  religious  scruples.  To  use  the  very  expressive 
terminology  of  Freud,  the  patient  is  in  a  state  of  permanent 
anxious  anticipation  which,  at  the  occasion  of  the  most 

1  Regis.     Manuel  prcctique  de  Medecine  mentale,  p.  279. 


324  PSYCHONEUROSES 

immaterial  and  trifling  occurrences,  develops  into  an  attack 
of  anxiety. 

Miss  Tvlargaret  F.,  forty-three  years  of  age,  private  teacher.  Family 
history:  father  alcoholic.  The  patient  is  of  normal  intelligence. 
Disposition  melancholy,  but  gentle  and  affectionate.  The  patient 
lived  for  twelve  years  with  the  same  family,  where  she  had  inspired 
a  true  attachment  for  herself.  She  has  had  no  serious  illnesses,  save 
frequent  attacks  of  migraine. 

The  onset  of  the  illness  dates  back  to  the  fall  of  1903.  The  young 
lady  whom  she  had  been  teaching  finished  her  education,  and  Miss  F. 
had  to  take  another  position.  This  grieved  her  very  much.  She 
gradually  grew  sad,  depressed,  and  became  disgusted  with  everything. 
In  November,  1903  (seven  months  after  her  change  of  position),  she 
began  to  have  all  kinds  of  doubts :  Has  she  said  her  prayers  properly? 
Has  she  not  made  a  mistake  in  asking  the  druggist  for  medicine?  Feel- 
ing herself  to  be  really  ill  she  left  her  new  position  and  went  home  to 
her  parents.  Her  morbid  preoccupations,  however,  persisted.  Her 
general  health  was  not  very  good.  She  lost  considerable  flesh  in  a 
short  time.     She  was  taken  to  a  sanatorium  on  January  4,  1904. 

An  examination  made  on  that  day  showed  the  following:  Stature 
slightly  below  the  medium.  Constitution  normal.  No  evident 
organic  disease  except  a  slight  degree  of  emaciation.  Lucidity  perfect. 
Patient  had  a  very  clear  realization  of  her  own  condition.  She  showed 
imeasiness  with  continuous  agitation:  walked  up  and  down  the  room, 
shifted  from  one  foot  to  the  other,  rubbed  her  hands  in  a  nervous  man- 
ner, looked  around  with  a  sort  of  apprehension,  doing  all  this,  she 
said,  in  spite  of  herself  and  without  any  definite  idea.  A  few  moments 
after  her  arrival  doubts  and  fears  made  their  appearance.  She  noticed 
a  bottle  of  syrup  on  a  table  in  her  room.  Immediately  she  began  to 
wonder  if  she  had  not,  without  knowing  it,  poured  something  into  the 
bottle,  perhaps  poison,  or  ink,  or  perfume.  Later  on  the  same  day, 
also  on  the  days  which  followed,  new  fears  developed  and  the  doubts 
increased.  The  following  is  a  transcript  of  some  of  the  case  notes 
from  the  records  of  this  patient. 

January  15.  Patient,  on  receiving  her  mail,  could  not  make  up 
her  mind  to  open  it.  The  nurse  opened  it  for  her.  The  patient  is 
afraid  to  sort  her  own  linen  or  clothing.  She  begs  the  nurse  to  examine 
minutely  every  piece  and  to  take  her  oath  that  no  injurious  powder 
has  been  found  on  the  fabrics  or  on  the  bed  linen.  She  knew  that  she 
had  on  her  arrival  at  the  sanatorium  121  fr.  75  cms.  in  her  pocket- 
book,  in  fact  she  had  written  the  amount  down  in  her  note  book,  yet 
she  was  in  doubt.  She  had  the  nurse  count  the  money  over  and  finally, 
still  doubting,  decided  to  write  to  her  mother  asking  whether  this  was 


PSYCHASTHENIA  325 

the  correct  amount.  In  the  evening  she  said  her  prayers,  kneehng  at 
the  bedside,  but  insisted  on  a  nurse  being  present  all  the  time  in  order 
that  she  might  have  proof  later  that  she  said  her  prayers  properly. 

January  17.  Patient  went  to  mass  and  had  prepared  three  10- 
centime  pieces  for  the  collection.  But,  contrary  to  her  expectation, 
the  collection  tray  went  around  only  twice;  there  remained,  therefore, 
one  10-centime  piece.  She  passed  the  entire  day  in  most  painful 
anxiety,  not  knowing  what  to  do  with  the  ten  centimes,  asking  herself 
whether  they  were  really  hers,  or  whether  she  had  inadvertently  taken 
them  from  the  collection  tray,  or  picked  them  up  from  a  neighboring 
seat. 

January  23.  Patient  fears  she  was  disrespectful  in  her  remarks 
to  the  physician.  This  is  probably  due  to  her  being  neglected,  because 
no  attention  is  paid  to  her  complaints.  But  it  is  also  her  own  fault 
that  she  is  left  to  herself:  perhaps  she  has  not  followed  the  doctor's 
advice,  as  she  should  have  done.  If  one  could  only  return  the  past! 
It  may  be,  too,  that  she  has  not  always  done  her  duty  toward  her 
relatives;  in  that  case  her  sufferings  are  but  the  punishment  of  heaven. 
On  close  inquiry  it  is  found  that  the  patient  has  no  true  self -accusations ; 
the  patient  herself  says  that  there  is  no  real  foundation  for  these  ideas, 
but  that  they  just  force  themselves  upon  her  mind. 

January  29.  The  patient  was  seized  with  fear  at  the  idea  of  going 
up  to  her  room  alone  to  find  a  handkerchief.  A  nurse  had  to  accom- 
pany her. 

February  9.  Patient  decided  to  go  out  for  a  walk  in  the  park; 
all  the  time  she  insisted  on  holding  the  nurse's  hand,  and  still  had 
to  come  back  after  a  few  minutes  because,  she  said,  she  was  very 
much  afraid.  "  Afraid  of  what?  "  the  nurse  asked  her.  "  I  don't 
know.  .  .  .  Was  there  not  an  accident  or  a  crime  in  the  park  several 
days  ago?  "  In  spite  of  all  assurance  on  the  part  of  the  nurse  that 
nothing  unusual  had  happened  the  patient  could  not  be  calmed,  but 
kept  asking  the  physician,  his  assistant,  and  the  nurse  the  same  question 
over  and  over  again. 

February  15.  At  the  table  the  nurse  emptied  a  package  of  vichy 
salt  into  a  glass  of  water.  The  patient  was  seized  with  great  terror. 
"  What  was  that  white  powder?  "  Vichy  salt,  they  told  her.  "  But 
has  there  not  been  some  mistake?  Is  it  not  some  kind  of  poison? 
Have  not  some  particles  of  it  fallen  on  my  plate?  "  Everybody  present 
assured  her  that  she  had  no  reason  to  be  alarmed,  that  no  mistake  was 
possible,  that  at  any  rate  her  plate  was  too  far  for  any  particles  from  the 
package  to  have  fallen  on  it,  but  all  to  no  piu-pose;  the  entire  luncheon 
hour  and  the  rest  of  the  afternoon  was  passed  by  the  patient  in  the 
same  state  of  anxiety. 

February  25.  Patient  wanted  to  have  aU  the  salt  cellars  on  the 
table  emptied  as  they  might  contain  something  injurious. 


326  PSYCHONEUROSES 

February  26.  Somebody,  in  relating  a  piece  of  news  from  the 
paper,  made  use  of  the  word  "  accident."  The  patient  uttered  a 
cry.  That  was  horrible,  she  declared,  such  words  ought  not  to  be 
uttered  in  her  presence,  they  cause  her  such  fear.  Later  it  appeared 
that  there  was  a  whole  list  of  words  that  she  ought  never  to  hear: 
crime,  poison,  death,  thief,  sanatorium,  asylum,  etc. 

March  2.  Patient  was  visited  by  a  friend.  She  seemed  to  derive 
no  pleasure  from  the  visit,  cried  a  great  deal,  and  took  no  interest 
in  the  news  her  friend  told  her.  At  the  supper  table  she  suddenly 
remembered  that  it  was  a  fast  day  and  refused  to  eat  any  meat.  She 
was  offered  some  eggs,  but  hesitated  a  good  half  hour  before  accepting 
them.  For  her  salvation  she  ought  to  be  content  with  some  peas. 
On  the  other  hand,  the  doctor  told  her  to  eat  meat,  which,  in  fact, 
would  be  better  for  her  health.  Further,  by  taking  the  eggs  would  she 
not  be  depriving  someone?  Finally  she  decided,  or  rather  it  was 
decided  for  her,  to  have  two  boiled  eggs.  But  she  did  not  cease  worrying 
and  during  the  entire  evening  kept  asking  herself  what  she  ought  best 
to  have  done. 

March  21.  The  patient  was  informed  that  her  relatives  had  de- 
cided to  take  her  home,  which  she  had  several  times  begged  them  to  do. 
Instead  of  being  pleased  she  became  despondent.  This  may  not 
be  prudent,  she  is  not  yet  cured,  who  will  take  care  of  her  at  home? 

On  the  following  day  she  was  discharged  from  the  sanatorium, 
unimproved. 


CHAPTER  IX 

HUNTINGTON'S  CHOREA 

Huntington's  chorea,  a  constitutional  affection  in  the 
strictest  sense,  occurring  on  a  hereditary  basis,  forms  a 
group  apart  from  and  apparently  entirely  independent  of 
the  other  constitutional  disorders  thus  far  considered. 
Arrests  of  development,  epilepsy,  dementia  prsecox,  para- 
noia, manic-depressive  psychoses,  involutional  melancholia, 
hysteria,  and  allied  conditions  often  enough  present  a 
history  of  similar  heredity,  but  at  least  as  often,  if  not  more 
so,  they  present  a  history  of  dissimilar  heredity,  so  that  we 
find  instances  of  two  or  more  of  them  existing  in  the  same 
family.  For  this  reason  it  is  generally  held  that  these  con- 
ditions, though  forming  clinically  fairly  distinct  entities, 
are  nevertheless  in  some  manner  related  to  each  other.  The 
case  is  different  with  Huntington's  chorea.  In  all  cases  in 
which  a  complete  family  history  has  been  secured  the 
heredity  which  was  found  has  been  similar.  Instances  of 
other  neuropathic  conditions  are,  indeed,  occasionally 
observed  in  the  families  of  patients  suffering  from  Hunting- 
ton's chorea,  but  they  are  relatively  so  infrequent  as  to  be 
readily  accounted  for  as  coincidences  essentially  without 
relationship  to  the  chorea  itself. 

Another  reason  for  assigning  to  Huntington's  chorea 
an  independent  position  among  the  constitutional  disorders 
is  the  special  manner  in  which  it  is  transmitted  by  heredity. 
Such  evidence  as  is  available  indicates  that  the  neuropathic 
conditions  enumerated  above  are  for  the  most  part  trans- 
mitted in  the  manner  of  Mendehan  recessives.     (See  Chap- 

327 


328  HUNTINGTON'S  CHOREA 

ter  I,  Part  I  of  this  Manual.)  Theoretically,  then,  the 
development  of  a  case  requires  a  convergent  heredity,  and  in 
practice  such  heredity  is  very  frequently  found  where  a 
complete  family  history  is  available;  furthermore,  the 
hypothesis  of  recessiveness  offers  an  explanation  of  the 
frequently  observed  fact  of  atavistic  heredity  in  connection 
with  cases  of  these  conditions.  Pedigrees  in  cases  of  Hun- 
tington's chorea  practically  never  show  either  convergent 
or  atavistic  heredity;  even  in  families  heavily  charged  with 
this  condition  an  individual  who  happens  to  be  free  from  it  is 
also  free  from  the  risk  of  transmitting  it  to  his  offspring; 
in  other  words  this  disease  does  not  skip  a  generation  as 
other  neuropathic  conditions  frequently  do.  Thus  Hun- 
tington's chorea,  considered  as  a  biologic  trait,  behaves, 
unlike  the  large  general  group  of  other  neuropathic  condi- 
tions, not  as  a  Mendelian  recessive,  but  as  a  dominant  in 
relation  to  the  normal  condition.^ 

The  disease  is  comparatively  rare,  yet  most  institutions 
for  the  insane  can  show  one  or  more  cases.  Both  sexes 
are  about  equally  affected.  The  age  of  onset  in  typical 
cases  is  between  thirty-five  and  fifty.  The  development  is 
gradual,  beginning  with  slight  irregular  movements  of  the 
face  and  upper  extremities  which  extend  slowly  over  the 
rest  of  the  body,  at  the  same  time  becoming  more  severe; 
the  movements  are  almost  constant,  ceasing  only  during 
sleep;  the  patient's  speech  becomes  affected  eventually, 
growing  indistinct  and  unintelligible.  There  are  no  dis- 
turbances of  sensation.  Mental  symptoms  appear  in  almost 
every  case  sooner  or  later:  "  a  weakness  of  judgment  and 
initiative,  absent-mindedness,  general  dissatisfaction  with 
surroundings,  a  growing  selfishness  and  irritability  are 
among    the    earhest    symptoms    observed."  ^     The    fully 

1 C.  B.  Davenport  and  E.  B.  Muncey.  Huntington's  Chorea  in 
Relation  to  Heredity  and  Eugenics.  Amer.  Jour,  of  Insanity,  Oct.,  1916. 
(Bulletin  No.  17,  Eugenics  Record  Office,  Cold  Spring  Harbor,  N.  Y.) 

2  A.  S.  Hamilton.  A  Report  of  Twenty-seven  Cases  of  Chronic 
Progressive  Chorea.     Amer.  Journ.  of  Insanity,  Jan.,  1808. 


SYMPTOMS  329 

developed  mental  picture  is  characterised  by  marked  irri- 
tability, ideas  of  persecution,  and  a  slow  but  progressive 
deterioration;  the  latter  consists  mainly  in  a  "  disinclina- 
tion toward  mental  exertion,  which  is  so  pronounced  that 
the  examination  becomes  very  difficult;  in  the  marked 
cases  it  interferes  even  with  such  simple  reactions  as  stat- 
ing whether  it  is  summer  or  winter,  and  seems  to  give 
rise  to  the  fact  that  the  patient  does  not  respond  at  all, 
or  responds  in  a  perseveratory  manner;  in  the  milder  cases 
it  shows  itself  in  calculation,  in  giving  time  relations,  and 
in  giving  the  substance  of  a  simple  story  read  to  them, 
leading  to  the  excuse  that  the  memory  is  bad,  that  they  are 
unable  to  tell  it,  etc.;  whereas,  on  the  other  hand,  in  the 
orientation,  even  in  the  worst  cases,  there  is  remarkably 
little  interference;  the  memory  of  actual  facts,  if  sufficiently 
insisted  upon,  is  found  to  be  quite  good."  ^  In  the  original 
description  of  the  disease  Huntington  mentioned  marked 
suicidal  tendency  as  being  very  common,^  and  this  observa- 
tion has  been  corroborated  by  most  of  the  later  writers. 

Huntington's  chorea  is  a  chronic,  slowly  progressive, 
incurable  affection.  It  cannot  be  said  to  be  in  itself  fatal, 
death  usually  occurring  at  the  end  of  many  years  from  some 
intercurrent  disease. 

While  the  majority  of  cases  correspond  fairly  closely 
to  the  above  description,  more  or  less  marked  variations 
from  the  most  common  type  are  frequently  seen.  The 
onset  may  occur  at  an  early  age,  even  in  childhood  or  in 
infancy,  or  later  than  usual,  in  advanced  senility;  the  symp- 
toms may  be  mild,  consisting  of  slight  movements,  limited 
in  distribution,  and  unaccompanied  by  any  mental  disorder; 
or  the  mental  deterioration  may  be  particularly  severe  and 
set  in  long  before  the  choreic  movements  develop.^ 

^  W.  G.  Ryon.  A  Study  of  the  Deterioration  Accompanying  Hunt- 
ington's Chorea.     N.  Y.  State  Hosp.  Bulletin,  Feb.,  1913. 

3  George  Huntington.  O71  Chorea.  The  Med.  and  Surg.-  Reporter, 
Apr.   13,   1872. 

^  C-  B.  Davenport.     Huntington's  Chorea  in  Relation  to  Heredity 


330  HUNTINGTON'S  CHOREA 

The  anatomical  changes  found  post  mortem  consist 
mainly  of  brain  atrophy,  shrinkage  of  cortical  cells  with 
dilatation  of  peri-cellular  spaces,  and  occasionally  internal 
hemorrhagic  pachymeningitis. 

and  Eugenics.    Proc.  of  the  National  Academy  of  Sciences,  Vol.  I,  p. 
283,  May,  1915. 


CHAPTER  X 

4CUTE  ALCOHOLISM;  PATHOLOGICAL  DRUNKENNESS 

The  term  drunkenness  is  here  used  to  designate  the 
nervous  and  mental  symptoms  by  which  acute  alcohoUc 
intoxication  manifests  itself.  - 

The  predisposition  to  the  state  of  drunkenness,  quite 
variable  in  different  subjects,  is  a  part  of  the  general  tendency 
of  the  individual  toward  nervous  and  mental  disorders: 
"  It  may  be  truly  said  that  alcohol  is  the  touchstone  of  the 
equihbrium  of  the  cerebral  functions."  ^ 

We  have  had  under  observation  ar  imbecile  whom  a 
single  glass  of  wine  sufficed  to  make  drunk. 

Drunkenness  is  somewhat  schematically  divided  into 
two  stages:    (1)  excitement,  and  (2)  paralysis.     In  reahty 

^  Fere.  La  Famille  nevropalhique.  Paris.  F.  Alcan. — This  state- 
ment is  correct,  everything  else  being  equal.  But  it  must  be  borne  in 
mind  that  there  are  other  factors,  besides  mental  instability,  that 
have  to  do  with  an  individual's  susceptibility  to  alcohol.  Age  is 
one  such  factor,  young  persons  being  more  susceptible  than  middle 
aged  or  old  ones.  But  by  far  the  most  important  factor  is  habit. 
We  know  well  that  it  is  not  xmcommon  for  morphine  addicts,  who 
have  gradually  acquired  a  tolerance  for  that  drug,  to  take  as  much 
as  twenty  grains  at  a  dose  with  no  other  than  a  mUd  euphoric  effect, 
whereas  one-fortieth  of  this  dose  produces  profound  sleep  in  an  ordi- 
nary person,  and  one-fourth  may  readily  prove  fatal.  We  know 
also  that  the  same  kind  of  tolerance  can  be  acquired  for  arsenic  and 
for  many  other  poisons,  and,  in  fact,  we  often  utilize  this  very  prin- 
ciple in  the  artificial  production  of  immunity  against  certain  micro- 
bic  toxines,  such  as  those  of  diphtheria  and  tetanus.  It  is  undoubt- 
edly so  also  in  the  case  of  alcohol,  for  it  is  on  the  basis  of  such  an 
acquired  tolerance  that  chronic  alcohohcs  often  boast  of  being  able  to 
"  stand  any  amount  "  or  at  least  of  being  "  always  able  to  navigate." 

331 


332  ACUTE  ALCOHOLISM 

paralysis  is  present  from  the  beginning,  but  in  the  first  stage 
it  is  limited  to  the  higher  psychic  functions  and  is  masked  by 
the  intensity  of  the  automatic  phenomena,  so  that  it  does  not 
become  evident  until  the  second  stage,  when  all  the  nervous 
and  mental  functions  become  involved  in  the  paralysis. 

First  Stage:  Excitement. — Psychic  inhibition,  the  first 
manifestation  of  the  paralysis,  is  seen  in  the  slow  asso- 
ciation of  ideas,  distractibility,  and  insufficiency  of  percep- 
tion.i  The  automatism  is  apparent  from  the  disconnected 
conversation,  which  may  show  true  flight  of  ideas,  abnormal 
pressure  of  activity,  more  or  less  marked  morbid  euphoria 
and  irritability,  impulsive  character  of  reactions,  and  ex- 
tremely voluble  speech.  The  moral  sense  and  regard  for 
common  conventionalities  gradually  disappear,  and  the 
patient  may  commit  ridiculous,  repugnant,  offensive,  or 
even  criminal  acts. 

Second  Stage:  Paralysis. — Paralysis,  confined  in  the 
preceding  stage  to  the  sphere  of  the  higher  psychic  func- 
tions, now  attacks  the  automatic  functions.  The  movements 
are  awkward  and  clumsy,  speech  indistinct,  gait  unsteady. 
Gradually  the  patient  falls  into  a  profound,  sometimes  coma- 
tose, sleep — the  final  stage — from  which  he  awakes  lucid 
but  with  a  confused  recollection  of  what  has  passed  and  with 
a  pronounced  sensation  of  mental  and  physical  fatigue. 

Such  is,  rapidly  sketched,  the  aspect  of  common  drunk- 
enness. From  the  accentuation  or  obliteration  of  certain 
features  result  the  diverse  abnormal  or  pathological  forms. 

Comatose  Drunkenness. — The  phenomena  of  excite- 
ment are  either  absent  or  very  transient.  From  the  begin- 
ning the  paralysis  affects  the  entire  brain.  The  patient 
sinks  and  remains  inert  and  insensible  for  several  hours. 
His  face  is  congested.  Gradually  the  comatose  state  is 
replaced  by  sleep,  from  which  the  j-atient  awalxs  without 
any  recollection  whatever  of  the  occurrences  immediately 
preceding  his  intoxication.     Sometimes  the  pulse  becomes 

^  Riidin.  Auffassung  und  Merkfdhigkeit  unter  Alkoholwirkung, 
Kraepelins  Psycholog.  Arbeiten,  Vol.  IV,  No.  3. 


PATHOLOGICAL  DRUNKENNESS  333 

small,  the  heart  weak,  the  breathing  labored,  and  in  some 
cases,  which  are  fortunately  rare,  the  patient  dies  in  collapse. 

Maniacal  Drunkenness. — Here  paralysis  occupies  a 
secondary  position  and  excitement  dominates  the  scene. 
The  phenomena  of  agitation  generally  develop  very  rapidly. 
All  of  a  sudden  the  drunkard,  while  still  at  the  saloon- 
keeper's bar,  is  seized  with  an  outbreak  of  furious  madness 
without  any  apparent  cause  or  provocation;  he  breaks 
objects  and  furniture,  becomes  noisy,  and  threatens  and 
attacks  those  about  him.  The  extreme  clouding  of  con- 
sciousness shows  that,  in  spite  of  appearances,  "psychic 
activity  takes  but  a  very  small  part  in  the  production  of 
the  outbreak,"  and  that  "  subjugated  by  this  automatic 
development  of  psycho-motor  activity  it  disappears  en- 
tirely." ^  Almost  always  numerous  psycho-sensory  disorders 
(hallucinations  and  illusions)  are  associated  with  the  clouding 
of  consciousness  and  excitement. 

The  attack  terminates  in  profound  sleep.  This,  as 
in  the  preceding  form,  is  followed  by  almost  complete 
amnesia. 

Convulsive  Drunkenness. — The  maniacal  form  of  drunk- 
enness resembles  closely  the  delirious  attacks  of  epilepsy. 
The  relation  between  epilepsy  and  acute  alcoholic  intoxica- 
tion appears  still  closer  when  we  consider  that  drunkenness 
may  clinically  assume  the  aspect  of  an  epileptic  seizure. 
This  is  explained  by  the  convulsive  properties  of  alcohol, 
which  have  been  demonstrated  experimentally.  Attacks 
precisely  like  those  of  essential  epilepsy  may  supervene  in  the 
course  of  common  drunkenness.  In  all  cases  they  imme- 
diately follow  the  alcoholic  excesses,  differing  in  this  respect 
from  those  epileptiform  seizures  which  supervene  in  the 
course  of  chronic  alcoholism. 

Delusional  Drunkenness. — This  curious  but  rare  form 
has  been  studied  by  Garnier.-  The  delusions  are  extremely 
variable:  ideas  of  persecution,  ambitious  ideas,  depressive 
ideas  with  suicidal  tendencies,  etc.  Delusional  drunken- 
Gamier.    La  folie  a  Paris. 


334  ACUTE  ALCOHOLISM 

ness  is  encountered  only  in  profoundly  neuropathic  in- 
dividuals. 

Pathological  Anatomy. — The  lesions  of  acute  alcoholic 
intoxication  have  been  studied  chiefly  in  animals  poisoned 
experimentally.  Macroscopically  there  are  congestion  and 
sub-pial  hemorrhages.  Microscopically  are  found,  in  addition 
to  engorgement  and  distention  of  the  blood-vessels,  nerve- 
cell  changes  consisting  principally  in  swelling  of  the  nuclei 
and  peripheral  chromatolysis.  These  lesions  are  most 
marked  in  the  motor  cells  of  the  spinal  cord,  but  they  exist 
also,  though  less  pronounced,  in  the  cells  of  the  cortex.^ 

Treatment. — This  of  course  varies  with  the  different 
forms.  Maniacal  or  delusional  drunkenness  requires  strict 
watching  and  immediate  isolation;  the  comatose  form 
requires  the  use  of  external  and  internal  stimulation  (friction, 
ammonium,  ether,  caffein). 

^  Marinesco. «  Semaine  m^dicale,  June  14,  1899. 


CHAPTER  XI 
CHRONIC  ALCOHOLISM 

Chronic  alcoholism  manifests  itself:  (1)  in  permanent 
symptoms  (the  stigmata  of  alcoholism),  and  (2)  in  episodic 
acQidents. 

I.    Permanent  Symptoms 
The  permanent  symptoms  are  psychic  and  physical. 

A.      PSYCHIC    SYMPTOMS 

There  is  weakening  of  all  the  psychic  functions. 

Intellectual  Sphere. — Intellectual  activity  and  capacity 
for  work  are  diminished.  The  patient  becomes  dull,  negli- 
gent, and  clumsy. 

The  disorders  of  memory  consist  in  definite  retrograde 
amnesia  by  destruction  of  impressions,  associated  with 
more  or  less  marked  anterograde  amnesia.  The  former  follows 
the  general  law  of  amnesia.  Its  course  is  slowly  progres- 
sive; but  it  is  rare  for  it  to  reach  as  complete  a  develop- 
ment as  it  does  in  general  paralysis.  The  anterograde 
amnesia  renders  it  difficult  or  even  impossible  for  the  patient 
to  acquire  new  impressions;  thus  the  stock  of  ideas  becomes 
more  and  more  impoverished. 

The  judgment  is  constantly  affected :  the  patient  realizes 
but  imperfectly  his  condition  and  the  importance  and  signif- 
icance of  his  acts. 

Emotional  Sphere. — As  in  most  affections  with  a  basis 
of  mental  deterioration,  we  find  in  chronic  alcoholism  indif- 
ference associated  with  morbid  irritability. 

335 


336  CHRONIC  ALCOHOLISM 

The  chronic  alcoholic  is  not  at  all  concerned  with  his 
ruined  business,  the  misery  of  his  family,  or  the  compromise 
of  his  honor.  Only  the  desire  for  alcohol  can  still  arouse 
him  from  his  mental  torpor.  The  atrophy  of  the  moral 
sense,  which  in  these  cases  goes  hand  in  hand  with  the 
general  indifference,  is  such  that  in  order  to  procure  his 
favorite  drinks  the  patient  does  not  hesitate  to  make  use  of 
the  most  unscrupulous  means  and  to  associate  with  the 
vilest  characters.  If  he  still  works,  he  spends  his  earnings 
on  drink.  If  he  does  not  work,  as  is  the  rule  in  such  cases, 
he  accumulates  debts  in  the  lowest  drinking  dens,  extorts 
from  his  relatives  what  little  money  they  may  have  earned 
by  hard  labor,  and  he  may  even  resort  to  stealing. 

The  irritability  and  the  impulsive  tendencies  give  rise 
to  violent,  terrible  outbursts  of  anger,  and  often  to  assaults 
and  attempts  of  murder. 

Delusions  may  appear  at  times,  almost  always  those 
of  persecution  or  of  morbid  jealousy.  When  they  become 
more  developed  and  acquire  a  certain  fixedness  they  con- 
stitute alcoholic  delusional  states,  which  we  shall  study 
farther  on. 

Still  the  patient's  obscure  consciousness  presents  at  times 
a  temporary  lucidity.  Strong  remonstrances  of  friends  or 
grave  disorders  of  the  general  health  may  give  birth  to  re- 
pentance. The  unhappy  subject  regrets  his  excesses,  declares 
himself  a  great  sinner,  swears  by  all  that  is  holy  that  he  will 
not  take  another  drop  of  wine  or  liquor,  and  announces  his 
intention  to  join  a  temperance  association.  These  good 
resolutions  are  carried  out  for  several  days,  weeks,  or  even 
months;  but  almost  always  the  patient  falls  again :  his  feeble 
will  gives  way  and  he  can  struggle  no  longer.  He  is  in  a 
vicious  circle:  he  drinks  because  his  will  is  weak,  and  his 
will  is  weak  because  he  drinks. 

When  they  attain  a  certain  degree  of  intensity,  the 
mental  disorders  which  I  have  sketched  constitute  alcoholic 
dementia. 

Alcoholic  dementia  is  slowly  progressive.     It  takes  years 


PHYSICAL  SYMPTOMS  337 

to  become  fully  established.  Moreover — and  this  is  a  highly 
important  feature — it  ceases  to  progress  with  the  cessation 
of  the  alcohoHc  excesses. 

B.      PHYSICAL    SYMPTOMS 

The  sleep  is  diminished,  restless,  disturbed  by  unpleasant 
dreams.  The  patient  is  apt  to  dream  that  he  is  at  his 
occupation  (occupation-dreams) ;  the  work  is  pressing,  but 
in  spite  of  his  diligence  he  is  always  behind  and  the  results 
are  unsatisfactory.  At  other  times  veritable  dramas  are 
enacted:  assassins  pursue  him,  rats  run  at  him,  snakes  and 
monstrous  spiders  creep  over  him  (zoopsia).  These  dreams 
present  all  the  characteristics  of  delirium  tremens,  which 
has  been  aptly  called  a  prolonged  dream.  Sometimes  the 
patient  wakes  up  in  the  midst  of  his  nightmare  with  his 
head  heavy,  the  body  covered  with  perspiration,  still  doubt- 
ing the  inanity  of  his  terrors. 

Attacks  of  vertigo  and  flashes  of  hght,  which  often 
precede  and  usher  in  apoplectiform  attacks,  occur  in  some 
cases. 

The  motor  disturbances  consist  in  muscular  weakness, 
chiefly  marked  in  the  lower  extremities,  a  tendency  to 
lassitude,  and  a  constant  tremor  affecting  especially  the 
tongue  and  hands;  the  digital  tremor  is  rendered  very 
apparent  when  the  patient  holds  out  his  hand  and  slightly 
spreads  out  his  fingers:  it  is  a  fine,  vertical  tremor,  not 
very  rapid. 

The  tendon,  reflexes  are  sometimes  exaggerated,  but 
much  more  frequently  diminished  or  abolished;  the  cuta- 
neous reflexes  are  usually  exaggerated  (plantar  reflex), 
especially  in  intoxications  by  the  essences  (absinthe); 
sometimes  they  are  abolished;  the  pupils  are  paretic  and 
sometimes  sUghtly  myotic.  Occasionally  there  is  a  slight 
degree  of  strabismus  or  of  ptosis.  Vision  is  frequently 
impaired,  due  to  retrobulbar  neuritis;  there  is  diminution 
of  the  acuteness  and  there  may  be  a  "  central  scotoma  having 


338  CHRONIC  ALCOHOLISM 

the  shape  of  an  elHpse  the  long  axis  of  which  is  horizontal  " 
(Babinski) . 

Cutaneous  sensibility  is  reduced  in  the  large  majority 
of  cases;  the  hyposesthesia  is  often  unilateral;  in  such 
cases  it  is  associated  with  other  hysteroid  manifestations: 
hysterogenic  zones,  globus  hystericus,  absence  of  the  pharyn- 
geal reflex. 

Among  the  disorders  of  deep  sensibility  are  to  be  noted 
numbness,  tingling,  hypersesthesias  of  portions  of  muscles 
which  are  painful  on  pressure  or  are  cramped;  dull  pains 
with  lancinating  paroxysms  resembling  the  hghtning  pains 
of  tabes. 

The  motor  and  sensory  disturbances,  whatever  their 
distribution  may  be,  are  usually  due  to  polyneuritis,  which  is 
a  frequent  manifestation  of  chronic  alcoholism. 

The  gastro-intestinal  disorders  are  manifested  by  ano- 
rexia, pyrosis,  "  dry  retching  "  in  the  morning,  slow  and 
painful  digestion,  and  constipation. 

The  liver  is  often  enlarged,  and  so  is  also  the  spleen. 
True  alcohoUc  cirrhosis  is  sometimes  met  with,  but  assumes 
a  special  aspect,  the  principal  peculiarity  of  which  is  absence 
of  ascites. 

Diagnosis. — Chronic  alcoholism  is  to  be  differentiated 
chiefly  from  those  diseases  in  which  there  is  mental  deterio- 
ration: dementia  prsecox,  general  paralysis,  and  senile 
dementia.  The  student  is  referred  to  the  chapters  devoted 
to  these  diseases  for  discussions  of  differential  diagnosis. 

Prognosis. — This  is  always  grave.  The  symptoms  of 
mental  deterioration  once  established  are  not  likely  to  become 
abated.  The  timely  suppression  of  alcohol  prevents  their 
appearance  or,  if  they  are  already  present,  arrests  their 
progressive  course.  Unfortunately  this  is  very  difficult 
to  accomplish. 

Pathological  Anatomy. — The  arterial  system  is  the  seat 
of  atheromatous  degeneration  the  intensity  and  extent  of 
which  are  variable;  it  affects  especially  the  arteries  of  the 
brain.     Atheromatous  changes  in  the  arteries  at  the  base 


ETIOLOGY  339 

are  frequent,  though  not  constant.  The  arterioles  and 
capillaries  may  present  a  state  of  degeneration  characterized 
by  the  presence  of  granular  masses  containing  nuclei,  which 
indicate  their  cellular  origin. 

The  nerve-cells  undergo  ''  a  certain  degree  of  granulo- 
pigmentary  and  fatty  degeneration."  ^  The  nerve  fibers, 
especially  the  tangential  and  commissural  fibers,  are  partially 
atrophied. 

The  extent  of  the  lesions  in  the  nervous  elements  is  pro- 
portionate to  that  of  the  mental  deterioration.  Therefore 
it  is  especially  marked  in  cases  of  advanced  dementia. 

The  organs  of  the  vegetative  functions  present  the  usual 
lesions  of  alcoholism:  myocarditis,  interstitial  nephritis, 
alcoholic  gastritis,  fatty  degeneration  of  the  liver.  The 
hepatic  lesions  have  become  of  special  interest  since  Klippel 
has  shown  that  they  are  the  immediate  cause  of  certain  deliria 
occurring  in  alcoholics. 

Etiology. — How  does  one  become  an  alcoholic?  This 
question  resolves  itself  into  two  other  questions,  as  follows: 

1.  Why  does  a  given  individual  drink  alcohol  in  injurious 
doses? 

2.  Why  are  certain  nervous  systems  more  susceptible 
than  others  to  the  poisonous  action  of  alcohol? 

It  would  require  a  volume  to  reply  fully  to  the  first 
question;  indeed,  it  would  mean  a  solution  of  the  gigantic 
problem  of  alcoholism  in  its  social  relations.  According 
to  Kraepelin,  heredity  seems  to  play  a  certain  role.  The 
tendency  to  alcoholic  excesses  is  transmitted  to  descendants. 
Fere  also  states  that  "  to  become  an  alcoholic  one  must  be 
alcohoUzable ;  the  mere  indulgence  in  fermented  beverages 
is  not  in  itself  sufficient."  This  factor  is  of  some  importance, 
though  slight  as  compared  with  social  factors.  Among 
the  latter  the  most  powerful  is  undoubtedly  the  widespread 
ignorance  of  the  true  action  of  alcohol,  as  well  as  the  false 
disastrous  notion  prevailing  among  all  classes  of  society 
that  alcohol  gives  strength  and  is  therefore  indispensable 

1  Klippel.     Du  delire  alcoolique.     Mercredi  medical,  Oct.,  1893. 


340  CHRONIC  ALCOHOLISM 

to  the  workingman  in  the  performance  of  hard  labor. 
Though  it  is  to-day  a  well-estabHshed  fact  in  the  medical 
and  scientific  world  that  alcohol  produces  but  an  illusion 
of  strength  and  that  the  sense  of  increased  energy  which  it 
gives  is  but  a  morbid  subjective  phenomenon,  this  idea  is 
stUl  looked  upon  by  the  public  as  an  innovation  of  doubtful 
certainty,  "  an  invention  of  the  doctors." 

To  ignorance  is  joined  the  element  of  suggestion.  There 
can  be  no  doubt  that  many  begin  to  drink  by  chance  or  by 
example.  For  a  laborer  in  some  countries  it  is  almost  im- 
possible in  his  social  intercourse  to  escape  alcohoUsm,  even 
though  he  may  be  aware  of  its  dangers.  His  comrades  drag 
him  into  the  saloons,  \yhich  constitute  perpetual  tempta- 
tions on  his  way.  Refusal  to  accept  their  invitations  exposes 
him  to  their  ridicule  and  ill-treatment,  and  condemns  him  to 
the  isolation  of  a  social  outcast;  here,  as  everj'where  else, 
"to  do  as  others  do  "  is  the  great  principle  that  governs 
the  indi\ddual  and  obliges  him  to  conduct  himself  against 
his  own  interest  and  even  against  his  own  inclinations. 

Among  the  social  causes  there  are  a  great  many  special 
factors,  one  of  which  deserves  special  mention,  namely, 
grief.  Some  alcoholics  abandon  themselves  to  drink  on 
account  of  financial  ruin,  others  because  of  domestic  unhappi- 
ness,  etc.  However,  it  is  to  be  remembered  that  very  often 
patients  claim  their  misfortunes  to  have  been  the  cause  of 
their  intemperance,  while  in  reality  they  are  the  effect. 
The  drunkard  pretends  that  he  drinks  to  find  relief  from 
his  domestic  troubles,  while  in  fact  his  intemperance  has 
caused  them. 

We  now  have  to  answer  the  second  question:  Why 
does  alcohol  exert  a  rapid  and  intense  action  upon  certain 
nervous  systems,  while  others  resist  successfully  much 
greater  excesses? — It  is  here  that  individual  predisposition 
comes  into  play. 

Like  the  symptoms  of  acute  alcoholism,  those  of  chronic 
alcoholism  appear  chiefly  in  predisposed  individuals;  and 
the  greater  the  predisposition  the  more  rapidly  do  these 


TREATMENT  341 

symptoms  develop.  We  see  daily  in  general  hospitals 
patients  presenting  atheroma  of  the  arterial  system,  alcoholic 
cirrhosis,  etc.,  and  showing  but  slight  if  any  nervous  or 
mental  disorders;  while  in  insane  hospitals  patients  are 
admitted  whose  alcoholic  excesses  have  been  relatively 
slight  and  whose  nervous  systems  have  nevertheless  already 
suffered  irreparable  damage.  The  quality  of  the  soil  is 
therefore  of  primary  importance. 

The  pathogenic  action  of  alcohol  is  also  favored  by  all 
factors  which  diminish  the  resistance  of  the  organism, 
such  as  stress,  grief,  want  of  sleep,  and  acute  or  chronic 
infectious  diseases  (tuberculosis) .  Thus  we  often  encounter, 
associated  in  the  same  subject,  the  abuse  of  alcohol,  pre- 
disposition, and  debilitating  influences. 

It  would  be  useful  to  know  which  among  the  alcoholic 
beverages  produce  so  great  a  toxic  action  as  to  be  particularly 
responsible  for  the  production  of  alcoholism.  Clinical 
evidence  seems  to  show  that  the  principal  factor  in  alcoholism 
is  the  quantity  and  not  the  quality  of  the  beverage  ingested. 
The  experiments  of  Joffroy  and  Serveaux  have  shown  clearly 
that  alcoholic  intoxication  is  due  to  ethyl  alcohol  itself,  and 
not  to  the  impurities  often  associated  with  it.  Therefore  all 
fermented  beverages  may  cause  alcoholism :  liquors,  alcoholic 
tonics,  wines,  beers,  ciders,  the  alcohol  of  beverages  as  well 
as  that  of  substances  used  in  the  industries.  However, 
"  a  given  quantity  of  alcohol  is  more  toxic  the  more  con- 
centrated it  is;  for  this  reason  the  stronger  alcoholic  bever- 
ages play  a  prominent  role  in  the  production  of  alcoholism."  ^ 

Treatment. — Alcoholism,  once  established,  requires  no 
other  treatment  than  abstinence  from  alcoholic  beverages. 
Generally  this  can  only  be  enforced  in  a  hospital  for  the  insane 
or  for  inebriates.^     The  patient,  on  being  cured  of  his  drink- 

1  Antheavune.  De  la  toxicite  des  alcools.  These  de  Paris,  F.  Alcan, 
1897.  This  work  contaias  the  results  of  the  experiments  of  Joffroy 
and  Serveaux. 

2  Serieux.  Les  establissements  pour  le  traitement  des  buveurs  en 
Angleterre  et  aux  Etats-Unis.      Projets  de  creation  d'asiles  d'alcooliques 


342  CHRONIC  ALCOHOLISM 

ing  habit  and  returned  to  normal  life  would  do  well  to  join 
a  total  abstinence  society  where  he  will  find  the  support  which 
his  wavering  will  power  is  still  in  need  of. 

II.    Episodic  Accidents 

The  episodic  accidents  of  chronic  alcoholism  are  of  four 
kinds:  delirium  tremens,-  acute  hallucinosis,  delusional 
states,  and  the  polyneuritic  psychosis. 

delirium  tremens 

The  prodromata  consist  in  an  accentuation  of  the  symp- 
toms of  chronic  alcoholism.  Sleep  is  more  than  ever  dis- 
turbed by  nightmares,  preceded  by  painful  hypnagogic 
hallucinations,  and  reduced  in  the  last  days  before  the 
attack  to  a  vague  somnolence.  Violent  headaches  and  a  sort 
of  inexplicable  uneasiness  usher  in  a  grave  affection. 

Psychic  Symptoms. — These  were  admirably  analyzed 
years  ago  by  Las6gue  and  more  recently  by  Wernicke. 
Three  chief  symptoms  dominate  the  scene:  disorder  of  con- 
sciousness, hallucinatory  delirium,  and  motor  excitement. 

The  disorder  of  consciousness  involves  exclusively  the 
notion  of  the  external  world,  i.e.,  allopsychic  orientation, 
leaving  intact  the  notion  of  personality,  i.e.,  autopsychic 
orientation  (Wernicke). 

Illusions  and  hallucinations  are'  constant  and  at  times 
incessant.  They  present  two  general  characteristics:  (1) 
they  are  painful;  (2)  they  are  combined  in  such  a  manner 
as  to  form  complete  scenes  and  create  around  the  patient  a 
whole  imaginary  and  often  fantastic  world.  They  affect 
all  the  senses,  but  the  most  interesting  among  them  are  those 
of  vision  and  general  sensibility. 

en  Aulriche  et  en  France.  Bullet,  de  la  soc.  de  med.  ment.  de  Belg., 
1895. — By  the  same  author.  L'assistance  des  alcooliques  en  Suisse  ct 
en  Allemagne.  Ibid. — -Also.  L'Asile  df  alcooliques  de  departement  de  la 
Seine.     Ann.  med.  psych.,  1895,  Nov.-Dec. 


DELIRIUM  TREMENS  343 

The  visions  of  delirium  tremens  are  always  mobile  and 
animated.  They  form  an  uninterrupted  succession  of 
strange,  painful,  or  terrifying  scenes.  At  the  same  time  that 
the  patient  has  visions  of  assassins  or  ferocious  and  horrible 
animals,  he  feels  their  blows,  bites,  or  their  repulsive  contact : 
the  murderer's  dagger  or  the  fangs  of  dogs  or  tigers  sink 
into  his  flesh,  spiders  run  over  his  face,  and  snakes  slip  and 
crawl  under  his  clothes. 

Two  principal  forms  of  delirium  inay  be  distinguished: 
(a)  occupation  delirium,  and  (6)  persecutory  delirium. 

(a)  Occupation  Delirium. — The  patient  imagines  that  he 
is  amongst  familiar  surroundings  and  at  his  usual  occupation. 
The  hallucinations  possess  remarkable  distinctness  and  in- 
tensity: the  cab  driver  leads  his  horses,  urges  them  on,  whips 
them,  and  runs  over  pedestrians  who  do  not  get  out  of  his 
way  quickly;  the  cafe  waiter  waits  upon  guests,  receives 
money,  shows  them  to  vacant  seats.  Like  the  dreams  of 
the  alcoholic  this  occupation  delirium  is  generally  of  a  pain- 
ful character. 

(6)  Persecutory  Delirium. — The  psycho-sensory  dis- 
orders assume  a  terrifying  character.  Grimacing  and 
horrible  forms  are  seen  in  the  folds  of  the  curtains,  on  the 
window-panes,  or  on  the  walls.  Assassins  come  out  of 
every  corner;  the  patient  hears  clearly  their  threats  and 
abuses  and  describes  their  costumes  and  their  weapons. 
He  sees  frightful  and  fantastic  animals;  rats,  snakes,  gigantic 
tigers  fill  the  room,  constantly  changing  their  shapes  and 
throwing  themselves  upon  the  wretched  subject,  who  repels 
them  with  desperate  efforts.  An  odor  of  poison  proceeds 
from  all  sides;  the  food  has  a  putrid  taste. 

The  motor  excitement  is  at  times  very  violent.  The 
patient  walks  to  and  fro  in  the  dormitory  or  in  his  room, 
seeks  his  clothes,  strikes  the  walls  to  open  a  passageway 
for  his  escape,  emits  cries  of  terror;  or  he  whistles  and  sings, 
assuming  in  the  intervals  a  conversational  tone,  as  he 
imagines  himself  surrounded  by  his  acquaintances.  The 
movements,  though  sudden  and  awkward,  always  have  a 


344  CHRONIC  ALCOHOLISM 

psychic  origin  (Wernicke);  it  is  true  that  they  are  deter- 
mined by  imaginary  representations  and  sensations,  but  they 
invariably  present  the  character  of  purposeful  acts.  The 
patient  who  beheves  himself  to  be  in  his  workshop  goes 
through  the  regular  movements  necessary  for  the  perform- 
ance of  his  habitual  work;  another,  the  victim  of  terrifying 
hallucinations,  executes  the  movements  of  flight  or  of 
defense. 

On  viewing  broadly  all  the  preceding  symptoms  we 
observe  that  the  hallucinations  of  delirium  tremens  are  like 
a  dream  in  action.  Just  as  a  sleeper  can  be  roused  so  can  the 
patient  be  momentarily  roused  from  his  delirium  by  a 
sudden  interpellation.  One  then  obtains  correct  responses, 
so  that  the  patient  may  create  the  impression  of  a  normal 
person.  But  as  soon  as  he  is  left  alone  he  relapses  into  his 
delirium  and  agitation. 

Physical  Symptoms. — The  tremor  of  chronic  alcoholism 
becomes  exaggerated  so  that  there  is  a  shaking  of  the  entire 
body. 

The  speech  presents  a  characteristic  tremulousness. 

At  times  a  slight  degree  of  syllabic  stuttering,  paraphasia, 
facial  paresis,  or  even  hemiparesis  appears,  showing  the 
participation  of  the  projection  centers  in  the  morbid  process. 

The  tendon  and  cutaneous  reflexes  are  usually  exag- 
gerated. 

A  certain  degree  of  hypercesthesia  is  the  rule.  The 
morbid  irritability  of  the  psycho-sensory  centers  explains 
the  facility  with  which  it  is  possible,  by  a  simple  suggestion 
or  by  slight  mechanical  stimulation,  to  bring  forth  a  halluci- 
nation, even  after  the  spontaneous  psycho-sensory  disorders 
have  disappeared  (induced  hallucinations  of  Liepmann).^ 

We  encounter  also  parsesthesias  and  even  anaesthesias. 

Fever  is  almost  a  constant  symptom;  its  presence  fur- 
nishes an  excellent  element  for  prognosis.  In  favorable  cases 
the  temperature  does  not  rise  beyond  39°  C,  reaching  its 
maximum  towards  the  end  of  the  second  day.  Deferves- 
1  Arch.  f.  Psychiatrie,  XXVI. 


DELIRIUM  TREMENS  345 

cence  takes  place  either  rapidly  or  by  lysis.  In  grave  cases 
the  temperature  rises  above  39°  or  even  40°  C. 

There  are  also  to  be  noted  a  dyspeptic  condition  of  the 
digestive  tract  which  is  often  very  marked;  usually  slight, 
sometimes  severe  albuminuria;  a  rapid,  full,  and  bounding 
pulse  which,  in  grave  forms,  becomes  small  and  easily  com- 
pressible. Under  these  unfavorable  circumstances  the 
general  nutrition  suffers  and  there  is  loss  of  flesh  which 
becomes  very  considerable  in  a  few  days. 

Complications. — Among  those  involving  the  nervous 
system  the  most  frequent  are  epileptiform  seizures  which 
may  precede  by  thirty-six  or  forty-eight  hours  the  onset  of 
the  delirium,  or  they  may  occur  during  the  attack.  The  most 
formidable  as  well  as  the  most  common  complication  is  pneu- 
monia, which  affects  chiefly  the  apex  of  one  lung  and 
assumes  from  the  beginning  a  grave  aspect. 

Prognosis. — There  are  two  possible  terminations:  recov- 
ery and  death. 

Recovery  is  the  rule.  It  takes  place  within  four  or  five 
days  after  a  deep  and  prolonged  sleep.  The  sleep  may 
come  on  suddenly  or  it  may  be  preceded  by  a  period  of 
calmness. 

The  duration  of  delirium  tremens  is  sometimes  abnor- 
mally brief  (several  hours),  and  at  other  times  abnormally 
long  (a  few  weeks  or  even  months). 

Convalescence  is  marked  at  the  beginning  by  a  certain 
amount  of  confusion  which  persists  for  some  time  and  which 
may  or  may  not  be  associated  with  delusions. 

Death  may  occur  from  exhaustion,  from  an  epileptiform 
attack,  or  from  some  complication  (pneumonia). 

Diagnosis. — Attacks  very  similar  to  delirium  tremens 
are  seen  outside  of  alcoholism,  notably  in  senile  dementia, 
general  paralysis,  and  meningitis  of  the  cerebral  convexity. 
In  the  latter  affection  the  diagnosis  is  based  upon  the  exist- 
ence of  specially  marked  and  numerous  focal  symptoms  such 
as  Jacksonian  epilepsy,  strabismus,  etc.,  upon  the  condition 
of  the  optic  disc,  and  upon  the  course  of  the  disease. 


346  CHRONIC  ALCOHOLISM 

The  points  of  differentiation  from  general  paralysis  and 
from  senile  dementia  will  be  studied  in  connection  with  these 
affections. 

Pathological  Anatomy. — To  the  lesions  of  chronic  alco- 
holism already  considered  are  added  exudative  hyperoemia 
and  inflammatory  diapedesis,  which  are  the  expression  of  an 
acute  process  analogous  to  that  observed  in  infections. 

The  nerve-cells  lose  their  normal  shape  and  structure, 
their  angles  become  blunted,  and  their  chromatophylic 
granulations  are  broken  up  or  disappear  entirely.  The  nerve 
fibers  degenerate. 

These  lesions  are  present  throughout  the  cortex,  including 
centers  of  projection.  It  is  not  rare  to  find  also  a  certain 
degree  of  degeneration  in  the  pyramidal  bundles  and  in  the 
posterior  columns. 

The  visceral  lesions  are  often  dependent  upon  some 
complicating  infection,  such  as  influenza,  infection  by  the 
pneumococcus,  or  typhoid  fever. 

The  heart  is  the  seat  of  a  myocarditis  which  in  many  of 
the  fatal  cases  constitutes  the  immediate  cause  of  death. 

The  liver  shows  degeneration  which  is  so  frequent  and  at 
times  so  pronounced  that  Klippel  ^  has  been  led  to  attribute 
delirium  tremens  to  autointoxication  of  hepatic  origin. 

The  lesions  in  the  kidneys  are,  according  to  Herz,^ 
those  of  acute  parenchymatous  nephritis.  He  states  that 
these  lesions  are  constant. 

Pathogenesis. — Delirium  tremens  is  not  to  be  con- 
sidered as  a  simple  alcoholic  intoxication,  a  sort  of  belated 
drunkenness  caused  by  an  accumulation  of  the  poison  in 
the  organism.  Its  clinical  aspect  in  fact  differs  radically 
from  acute  intoxication.  Moreover  it  is  apt  to  break  out 
even  after  several  days'  abstinence.     Finally,  the  patient 

^  Klippel.  Du  delire  des  alcooliques.  Lesions  anatomiques  et 
pathogenie.  Mercredi  medical,  Oct.,  1893. — De  Vorigine  hepatique 
de  certains  delires  des  alcooliques,  Ann.  med.,  psych.,  Sept.-Oct.,  1894. 

2  Abstract  in  Centralblatt  fiir  Nervenheilkunde  und  Psychiatrie, 
May,  1898. 


DELIRIUM  TREMENS  347 

recovers  even  when  alcohol  is  administered  in  large  doses 
during  the  delirium. 

Some  authors,  Wernicke  among  them,  attribute  delirium 
tremens  to  sudden  withdrawal  of  alcohol.  This  view  finds 
corroboration  in  the  army  experiences  during  the  World 
War.  In  all  National  Army  cantonments  the  arrival  of 
almost  every  contingent  of  drafted  recruits  was  followed 
within  a  few  days  by  the  development  of  a  crop  of  cases  of 
delirium  tremens  for  which  there  seemed  to  be  no  cause 
other  than  the  suddenly  enforced  abstinence. 

An  important  fact  upon  which  Joffroy  frequently  insisted 
in  his  lectures  is  that  delirium  tremens  often  breaks  out  at 
the  occasion  of  a  supervening  infection,  such  as  influenza, 
pneumonia,  or  suppuration.  Thus  it  seems  that  the  disease 
is  caused  by  two  agencies,  alcoholism  and  some  supervening 
condition,  most  frequently  an  infection. 

By  what  mechanism  does  their  combination  produce 
this  effect? — Possibly  by  determining  an  autointoxication 
by  insufficiency  either  of  the  liver  (Klippel)  or  of  the  kidneys 
(Herz). 

It  should  be  remembered,  however,  that  in  many  cases 
the  second  factor,  the  accidental  infection,  is  not  found. 
Perhaps,  reduced  to  some  disorder  possessing  in  itself  no 
apparent  gravity,  such  as  an  attack  of  gastric  indigestion, 
it  passes  unnoticed. 

If  it  is  true  that  delirium  tremens  is,  as  suggested  above,  a 
result  of  sudden  withdrawal  of  alcohol,  a  condition,  in  other 
words,  analogous  to  the  sjTiiptoms  of  abstinence  seen  in 
cases  of  drug  addiction,  then  its  development  in  cases  of 
supervening  acute  diseases  or  injuries  may  be  due  mainly 
to  the  abstinence  incidentally  resulting  from  the  patient's 
confinement  to  bed  either  at  home  or  in  a  hospital. 

Treatment. — Rest  in  bed  is  very  useful  and  is  applicable 
in  the  great  majority  of  cases.  More  than  in  any  other 
psychosis,  in  this  disease  mechanical  restraint  is  dangerous 
and  must  be  prohibited. 

The  administration  of  alcohol  is  a  time-honored  practice 


348  CHRONIC  ALCOHOLISM 

and  was  found  very  efficacious  in  the  army  cases  referred  to 
above.  It  seems  to  do  good  in  many  ways  and  in  many  types 
of  cases:  (1)  It  seems  capable  of  preventing  delirium  tremens. 
If  the  withdrawal  of  alcohol  in  a  case  of  chronic  alcoholism 
is  accomplished  not  suddenly,  but  gradually,  the  danger  of 
delirium  may  be  lessened  or  obviated.  (2)  In  the  prodromal 
period  or  very  soon  after  the  onset  of  delirium  tremens  the 
administration  of  alcohol  may  abort  the  attack.  (3)  In 
the  course  of  delirium  tremens  the  judicious  administration 
of  alcohol  seems  to  lessen  agitation,  improve  the  physical 
condition,  shorten  the  attack,  bring  early  sleep,  and  prevent 
exhaustion  with  its  possible  fatal  termination.  (4)  In 
cases  apparently  threatened  with  heart  failure  alcohol  seems 
to  be  the  most  efficacious  stimulant. 

The  food  should  be  substantial,  yet  such  as  would  least 
tax  the  digestive  system.  A  milk  diet  admirably  fulfills 
this  double  indication.  A  glass  every  hour  during  the  day 
may  be  given,  so  that  the  patient  will  get  about  2^  or  3 
quarts  a  day.  Sometimes  it  is  useful  to  add  eggs,  beef 
juice,  or  chopped  meat.  During  convalescence  full  diet 
may  be  gradually  resumed. 

As  regards  medication,  sedatives  and  hypnotics  may  be 
required  early  and  heart  stimulants  late  in  the  course. 
Bromides,  paraldehyde,  and  chloral  are  commonly  used  and, 
for  stimulation,  strychnin,  digitalein,  caffein,  and  ether. 
Alcohol  in  these  cases  seems  to  be,  however,  the  best  sedative, 
hypnotic  and  stimulant  and  its  administration  may  render 
all  other  medication  unnecessary. 

ACUTE  hallucinosis;  delusional  states 

Acute  hallucinosis  differs  from  delirium  tremens:  (1) 
in  the  predominance  of  hallucinations  of  hearing  over  those 
of  sight;  (2)  in  the  absence  of  any  marked  disorder  of  con- 
sciousness; and  (3)  in  its  course,  which  is  of  longer  duration. 

After  a  rather  prolonged  prodromal  period  marked,  as 
in  the  case  of  delirium  tremens,  by  an  accentuation  of  the 


ACUTE  HALLUCINOSIS  349 

symptoms  of  chronic  alcoholism,  the  patient  becomes  uneasy, 
distrustful,  and  suspicious.  Gradually  false  interpretations, 
illusions,  and  persecutory  ideas  become  established.  He  does 
not  dare  to  leave  the  house,  feeling  that  he  is  being  watched, 
insulted  or  threatened  by  passers-by  or  followed  by  the 
police.  Very  early  hallucinations  of  hearing  appear  followed 
often  by  hallucinations  of  other  senses. 

The  disease  rapidly  reaches  its  height  of  development 
and  then  presents  the  following  fundamental  features: 

(a)  Conservation  of  lucidity:  the  patient  remains  well 
oriented,  understands  questions,  and  answers  relevantly. 

(6)  Painful  character  of  the  delusions  and  of  the  psycho- 
sensory disorders:  ideas  of  persecution  of  a  variable  nature: 
fear  of  being  poisoned  or  assassinated,  ideas  of  jealousy; 
imaginary  insults  or  threats;  frightful  visions,  especially 
marked  at  night,  grimacing  figures,  ghosts,  detectives  coming 
to  take  the  patient  into  custody,  executioners,  etc.;  a  taste 
or  an  odor  of  poison  or  of  faecal  matter;  sensations  of  scald- 
ing, pricking,  or  electric  currents;  motor  hallucinations. 
These  latter  phenomena,  but  slightly  marked  in  the  majority 
of  cases,  point  to  a  grave  prognosis  when  they  assume  a 
certain  intensity;  they  often  forebode  a  prolonged  course  of 
the  disease  and  indicate  a  tendency  towards  mental  deteriora- 
tion. Hallucinations  of  taste  and  smell  often  cause  refusal 
of  food. 

(c)  Tendency  to  systematization:  the  patient  seeks  an 
explanation  and  a  cause  for  the  persecutions.  However, 
the  systematization  is  of  rapid  development  and  is  not 
always  very  accurate. 

(d)  Depressed  mood  and  aggressive  tendencies:  the  patient, 
profoundly  irritated,  wreaks  his  vengeance  upon  innocent 
victims,  being  determined  to  defend  himself  against  the 
persecutions  of  his  enemies  or  to  escape  them  by  any  possible 
means.  If  such  a  patient  desires  to  die  it  is  not,  as  other 
classes  of  patients,  for  the  purpose  of  expiating  some  crime 
or  of  finding  relief  from  remorse,  but  solely  to  escape  the 
frightful  tortures  prepared  for  him  by  his  enemies.     Often 


350  CHRONIC  ALCOHOLISM 

he  transforms  his  house  into  a  veritable  arsenal  and,  un- 
fortunately, does  not  limit  himself  to  mere  demonstrations, 
but  makes  use  of  his  weapons. 

The  somatic  disorders  of  chronic  alcoholism  are  all 
present  in  this  affection.  Sleep  is  diminished  and  filled 
with  the  pathognomonic  dreams. 

The  urine  often  contains  a  trace  of  albumen. 

As  a  general  rule  an  attack  of  acute  hallucinosis  tends 
toward  recovery.  This  takes  place  gradually  after  several 
weeks  or  at  most  several  months. 

The  prognosis  is,  however,  not  altogether  favorable, 
firstly  because  recurrencies  are  common,  and  secondly 
because  each  successive  attack  leaves  a  noticeable  trace 
upon  the  intelligence  and  accelerates  the  course  of  alcoholic 
dementia. 

It  is  of  great  importance  to  make  the  differential  diagnosis 
between  acute  hallucinosis  and  the  other  affections  in  which 
systematized  delusions  are  encountered,  viz.,  dementia 
prsecox,  delire  chronique,  and  paranoia.  The  reader  is  re- 
ferred to  the  respective  chapters  devoted  to  these  diseases 
for  the  points  of  differentiation.^ 

The  treatment  is  that  of  chronic  alcoholism.  The  violent 
reactions  usually  necessitate  commitment.  Attacks  of 
excitement  are  to  be  treated  by  the  usual  methods. 

Between  acute  hallucinosis  and  the  alcoholic  delusional 
states  there  is  no  sharp  line  of  demarcation;  the  principal 
distinction  is  in  the  predominance  in  the  latter  of  de- 
lusions, while  hallucinations  play  but  a  subordinate  part. 
Some  cases  are  acute,  of  brief  duration,  and  more  or  less 
closely  connected  with  sprees  or  unusual  excesses  in  drinking; 
others  are  chronic,  subsiding  only  in  part,  if  at  all,  upon  the 
withdrawal  of  alcohol  and  lighting  up  again  promptly  upon 
the  resumption  of  drinking  or  even  without  it  merely  upon  the 
patient's  return  from  the  institution  to  his  home  and  old 

1 G.  H.  Kirby.  Alcoholic  Hallucinosis,  with  Special  Reference  to 
Prognosis  and  Relation  to  Other  Psychoses.  Psychiatric  Bulletin  of 
the  N.  Y.  State  Hospitals,  July,  1916. 


POLYNEURITIC  PSYCHOSIS  351 

surroundings.  The  delusions  are  mostly  of  persecution  and 
often  may  be  plainly  seen  to  originate  from  a  subconscious 
effort  on  the  part  of  the  patient  to  place  upon  others  the  blame 
for  the  conditions  resulting  from  his  intemperance :  the  fellow 
workmen  annoy  him  in  various  ways,  have  plotted  against 
him,  have  caused  him  to  lose  his  position;  his  employer  dis- 
criminates against  him;  the  labor  unions  are  spreading  bad 
reports  about  him  to  prevent  him  from  getting  employment; 
especially  characteristic  are  delusions  of  jealousy  based,  for 
the  most  part,  on  misinterpretations  of  most  trivial  occur- 
rences: the  bedspread  is  wrinkled  as  though  somebody 
had  lain  on  it,  the  wife  leaves  the  house  too  often  claiming 
to  go  to  the  store  or  to  visit  her  mother,  the  milkman's 
"  Good-morning "  seems  suspiciously  friendly,  the  coffee 
tastes  queer,  probably  on  account  of  poison  put  in  by  the 
wife  to  get  rid  of  the  patient.  These  delusions  often  lead  to 
violent  quarrels,  disgraceful  scenes,  beating,  and  threats 
or  even  attempts  of  homicide. 

POLYNEURITIC    PSYCHOSIS 

The  polyneuritic  psychosis  or  Korsakoff's  disease  ^ 
is  an  affection  characterized  by  the  association  of  phenomena 
of  polyneuritis  with  specific  mental  disturbances  among  which 
amnesia  of  diverse  forms  constitutes  a  preponderant  feature. 
Although  it  occurs  most  frequently  on  a  basis  of  chronic 
alcoholism,  it  is  also  sometimes  observed  independently 
of  chronic  alcoholism,  following  a  profuse  hemorrhage  or 
an  infectious  disease,  such  as  influenza. 

Symptoms. — In  some  cases  the  symptoms  of  the  poly- 
neuritic psychosis  appear  gradually,  without  any  striking 
phenomena  at  the  onset;  much  more  often  the  onset  is 
acute:  agitation,  numerous  hallucinations,  and  anxiety 
render  the  resemblance  to  delirium  tremens  so  marked  as  to 
lead  frequently  to  errors  in  diagnosis.     After  several  days  the 

1  Congres  de  Medecine,  1889. — Luckerath.  Beitrag  zu  der  Lehre 
von  der  Korsakow' schen  Psychose.     Neurol.  Centralblatt,  April,  1900. 


352  CHRONIC  ALCOHOLISM 

agitation  subsides,  but  the  disorientation  persists  and  the 
characteristic  amnesia  appears  together  with  the  phenomena 
of  polyneuritis. 

The  amnesia  is  both  anterograde  and  retrograde. 

The  anterograde  amnesia  results  from  the  total  abolition, 
or  at  least  a  marked  diminution,  of  the  power  of  fixation. 
The  patient  forgets  in  a  few  moments  a  visit  which  he  has 
received  or  the  gist  of  what  he  has  just  read.  On  leaving 
the  table  he  asks  whether  it  is  not  almost  time  for  dinner  and 
complains  of  having  no  appetite. 

The  retrograde  amnesia  is  purely  functional,  by  default 
of  reproduction;  in  the  course  of  timie  old  representations 
reappear  intact. 

The  effacement  of  representations  occurs  in  conformity 
to  the  law  of  retrogression.  Depending  upon  the  severity 
of  a  particular  case,  the  amnesia  involves  the  events  of  a 
more  or  less  considerable  period  of  time. 

Pseudo-reminiscences,  illusions  and  hallucinations  of 
memory  fill  the  gaps  created  by  the  amnesia.  Thus  quite 
frequently  the  patient  is  totally  unconscious  of  his  disorder 
of  memory  and  unhesitatingly  replies  to  all  questions  put 
to  him.  Often  also,  modifying  facts  of  which  his  impres- 
sion is  more  or  less  vague,  adjusting  some  details  and  sup- 
pressing others,  the  patient  narrates  imaginary  occurrences 
the  principal  features  of  which  are  their  mobility,  their  easy 
modifiability  by  appropriate  suggestion,  and  their  being 
usually  limited  to  the  bounds  of  possibility.  The  latter 
characteristic  is,  however,  not  constant,  for  the  fabrications  in 
the  polyneuritic  psychosis  may  be  altogether  improbable  or 
even  absurd. 

The  following  specimen  has  been  taken  from  an  observa- 
tion made  upon  a  case  of  polyneuritic  psychosis  due  to 
absinthe : 

Q.  How  long  have  you  been  here? 
A.  Since  this  morning. 
Q.  What  were  you  doing  yesterday? 

A.  I  went  to  the  market  to  buy  some  eggs.  After  that  I  went  to 
see  my  sister  and  took  dinner  with  her. 


POLYNEURITIC  PSYCHOSIS  353 

Q.  Don't  you  ever  go  to  the  theatre? 

A.  Oh,  that's  true,  ...  I  went  there  after  work  last  night  .  .  , 
it  was  very  beautiful. 

Q.  What  play  did  you  see? 

A.  Really  .  .  .  just  wait  a  minute  ...  it  was  very  beautiful  .  .  . 
thej''  sang  .  .  .  they  had  superb  costumes  ...  I  cannot  recollect  the 
name  of  the  play. 

In  reality  the  patient,  who  had  been  in  the  hospital 
during  the  three  weeks  previous,  had  not  left  his  bed  since 
his  admission  on  account  of  very  marked  paresis  of  both 
lower  extremities. 

To  these  pathognomonic  disturbances  of  memory  are 
added  also  complete  loss  of  orientation  of  time  and  place, 
numerous  illusions  which  often  lead  to  mistakes  of  identity 
and  occasional  hallucinations  which  are  more  or  less  fleeting. 

The  emotional  tone  is  usually  one  of  indifference;  some- 
times there  is  slight  euphoria  or  undue  irritability. 

In  spite  of  their  intensity  the  psychic  symptoms  are  in 
many  cases  not  very  apparent  at  first.  The  patients  are 
quiet,  understand  well  the  questions  put  to  them,  and  reply 
in  a  calm  and  often  even  in  an  intelligent  manner.  They 
often  appear  to  be  normal  because  a  conversation  of  several 
minutes  may  not  suffice  to  reveal  the  pathognomonic  amnesia 
and  disorientation. 

The  signs  of  'polyneuritis,  paresis  of  the  lower  extremities, 
abolition  of  the  tendon  reflexes,  pargesthesias,  pains,  hyper- 
aesthesias  of  circumscribed  muscular  masses — to  mention  only 
the  principal  ones — vary  widely  in  intensity.  They  are  at 
times  mild,  while  the  mental  disturbance  may  be  quite 
marked.  Possibly  they  may  be  even  entirely  wanting  in 
certain  cases  that  are  perfectly  typical  from  the  psychic 
standpoint. 

The  general  health  is  usually  affected  to  some  extent. 
Occasionally  cachexia  may  develop  and  end  fatally.  Also 
cardiac  disturbances  are  often  noted,  feeble  action,  irregular- 
ity, etc.,  which  in  a  number  of  cases  are  dependent  upon  a 
neuritis  of  the  pneumogastric  nerve. 


354  CHRONIC  ALCOHOLISM 

Duration,  Prognosis,  Diagnosis. — The  duration  of  the 
active  period  of  the  disease  is  usually  several  months,  seldom 
over  a  year.  There  then  remains  a  characteristic  state  of 
mental  deterioration  dependent  upon  a  persisting  and  more 
or  less  pronounced  impairment  of  the  power  of  retention, 
with  resulting  disorientation  and  amnesia  for  recent  occur- 
rences. The  tendency  toward  active  fabrications  and 
pseudo-reminiscences  becomes  less  marked  and  often  dis- 
appears. 

In  some  few  cases  there  is  partial  restoration,  so  that 
the  patients  are  again  able  to  keep  track  of  dates  and  current 
events,  but  complete  recovery  is  a  rare  exception  in  alcoholic 
cases,  though  it  is  said  to  be  common  in  cases  with  a  different 
etiology. 

Another  mode  of  termination,  also  infrequent,  is  death, 
which  results  either  from  cachexia  or  from  some  complica- 
tion: influenza,  pneumonia,  tuberculosis. 

The  diagnosis  is  based  on  (a)  the  very  marked  and 
characteristic  disorders  of  memory;  (6)  apparent  lucidity 
of  the  patient,  contrasting  with  the  real  disorientation; 
(c)  coexisting  signs  of  polyneuritis. 

Treatment. — Treatment  in  the  acute  stage  of  the  disease 
consists  chiefly  of  rest  in  bed  combined  with  a  reconstructive 
diet. 

It  is  scarcely  necessary  to  add  that  abstinence  from 
alcohol  should  be  rigorously  enforced,  especially  where 
alcoholism  is  the  cause. 


CHAPTER  XII 
DRUG  ADDICTIONS 

It  would  seem  that  the  use  of  narcotics  in  one  form  or 
another  is  based  on  a  deeply  rooted  universal  human  craving. 

The  manner  of  gratification  of  this  craving  varies  in  dif- 
ferent parts  of  the  world  according  to  local  conditions  and 
racial  customs. 

The  substances  most  commonly  used  are  alcohol,  opium, 
Indian  hemp,  coca,  and  tobacco. 

The  following  table  shows  the  annual  per  capita  con- 
sumption of  alcohol  among  Caucasian  peoples.^ 

TABLE  14. 

France 3 .  72  gallons 

Spain 2.42 

Germany 2 .  09 

Great  Britain  and  Ireland 2 .  05 

United  States 1 .  16 

Russia 60 

Canada 54 

Opium  eating  is  chiefly  practiced  in  Asia  Minor,  Persia, 
and  India.  In  the  city  of  Balasur,  British  India,  which  may 
be  taken  as  a  typical  example,  one  in  every  twelve  of  the  pop- 
ulation is  an  opium  eater.  Opium  smoking  has  long  prevailed 
in  China  and  on  the  islands  of  the  Indian  Archipelago, 
although  recently  measures  have  been  taken  by  the  govern- 
ments for  its  suppression.  Various  products  of  Indian 
hemp  (hashish,  hhang,  ganja,  charas)  are  used  very  generally 
among  the  Mussulman  and  Hindu  population  of  India  and 
to  a  great  extent  also  among  the  Arabs,  Egyptians,  and 
1  Year  Book  of  the  Anti-Saloon  League,  1908 
355 


356  DRUG  ADDICTIONS 

African  negroes.  Bhang  is  used  in  India  for  smoking  and 
an  infusion  of  it  in  water  is  used  as  an  intoxicating  beverage. 
Coca  leaves  are  used  for  chewing  very  generally  by  Indians 
in  Bolivia,  Peru,  Ecuador,  Colombia  and  Rio  Negro.  Three 
or  four  times  a  day  labor  is  suspended  for  chacchar  or  acullicar, 
as  the  chewing  of  coca  is  termed.  Tobacco  is  used,  as  all 
know,  universally  for  smoking,  chewing,  or  in  the  form  of 
snuff.  The  world's  annual  production  of  tobacco  amounts  to 
nearly  two  and  a  half  billion  pounds.^ 

In  the  great  majority  of  instances  these  substances  are 
used  in  moderation  without  apparent  harm.  But  in  a 
certain  small  percentage  of  users  pathological  addiction 
develops  leading  to  intemperate  use  and  chronic  intoxication. 
The  drug  in  such  cases  becomes  a  necessity  to  the  organism, 
and  its  suppression  causes  a  train  of  physical  and  psychic 
disturbances  known  as  symptoms  of  abstinence. 

Etiology. — The  moderate  use  of  any  of  the  above-men- 
tioned habit-forming  drugs  in  communities  where  it  is  a 
general  or  prevalent  custom  cannot  be  regarded  as  patho- 
logical and  therefore  does  not  concern  us  here.  However, 
the  fact  that  such  a  custom  prevails  is  responsible  for  the 
development  of  a  good  many  cases  of  pathological  addiction 
which  would  not  develop  under  other  circumstances. 

In  this  country  drug  addiction  is  not  infrequently  seen 
among  those  who,  by  reason  of  their  occupation  or  special 
environment,  can  readily  procure  drugs:  physicians,  their 
wives,  medical  students,  pharmacists,  nurses,  laboratory 
attendants. 

However,  neither  access  to  drugs,  nor,  as  we  have  seen, 
its  more  or  less  habitual  use  in  moderation  suffices  to  produce 
pathological  addiction.  The  character  of  the  soil  is  an 
important  factor.  A  constitutional  condition  somehow 
related  to  the  great  neuropathic  group  seems  to  be  the  soil 
on  which  drug  addiction  grows.  Evidence  for  this  is  to  be 
found  in  the  family  and  personal  histories  of  drug  addicts. 

1  Encyclopedia  Britannica,  11th  edition,  articles  on  Opium,  China, 
Hemp,  Bhang,  Coca,  and  Tobacco. 


ETIOLOGY  357 

In  the  family  histories  are  to  be  found  cases  of  psychoses, 
psychoneuroses,  mental  deficiency,  inebriety,  constitutional 
psychopathic  states,  temperamental  anomalies,  epilepsy, 
etc.  In  the  personal  histories  are  to  be  found  for  the  most 
part  psychoneuroses  and  constitutional  psychopathic  states. 
Thus,  prior  to  the  development  of  drug  addiction  many  pa- 
tients have  criminal  records,  are  gangsters,  pimps,  gamblers, 
prostitutes,  embezzlers,  etc. 

The  constitutional  character  defects  of  drug  addicts 
become  accentuated  through  the  chronic  effect  of  the  drug. 
It  is  significant  in  this  connection  that  the  English  word 
assassin  is  derived  from  the  Arabic  hashishin,  meaning 
hashish  eaters. 

The  habit  is  started  sometimes  through  medication, 
occasionally  through  curiosity  and  the  desire  to  experience 
new  sensations,  but  most  frequently  through  the  example 
and  proselytism  of  older  addicts. 

The  drug  most  frequently  used  by  addicts  in  this  country, 
particularly  in  the  Eastern  states,  is  heroin,  95%  of  all 
being  addicted  solely  or  chiefly  to  this  drug.  Follow- 
ing this  in  order  of  frequency  are  opium,  morphine,  and 
cocaine.     In  France  cocaine  addiction  is  the  most  common.^ 

The  age  at  which  the  habit  is  contracted  is  usually  be- 
tween fifteen  and  twenty.  The  most  common  ways  of  tak- 
ing it  are  by  hypodermic  injection  into  the  arms,  thighs, 
abdomen,  or  chest;  by  snuffing;  by  smoking  (opium); 
and  by  the  mouth. 

The  dosage  of  heroin,  morphine,  or  cocaine  in  estab- 
lished cases  varies  from  0.5  to  2  grams  per  day;  in  some 
cases  this  maximum  is  exceeded.^ 

The  following  description  of  the  S5miptoms  and  course  of 
morphine  addiction  largely  holds  good  for  other  drug  addic- 
tions as  well. 

Many  morphine  addicts  take  their  mjections  without 

^  J.  Rogues  de  Fursac.     In  a  personal  communication.    ■ 
2  S.    R.    Leahy.     Some   Observations   on   Heroin   Habitues.     N.  Y. 
State  Hosp.  Bulletin,  Aug.,  1915. 


358  DRUG  ADDICTIONS 

regularity  or  precaution  and  at  any  opportunity;  others, 
in  true  epicurean  fashion,  select  the  moment  and  condi- 
tions when  they  can  enjoy  most  profoundly  their  favorite 
pleasure.  Some,  again,  have  their  hours  regularly  fixed, 
use  only  accurately  prepared  solutions  of  a  certain  strength, 
and  take  all  antiseptic  precautions;  many  take  their  daily 
quantity  in  divided  doses;  others  take  a  single  large  dose 
daily  in  order  to  obtain  the  most  intense  effect. 

According  to  Chambard  four  periods  may  be  distin- 
guished in  the  career  of  a  morphine  addict,  which  follow 
one  another  by  imperceptible  transitions. 

First  Period :  Initiation  or  Euphoria. — It  has  been  aptly 
called  the  honeymoon  of  the  morphine  addict.  Under  the 
influence  of  the  morphine  physical  pains,  if  they  exist, 
disappear  or  become  abated,  organic  functions  become 
active,  and  the  mind  lapses  into  a  pleasant  reverie;  ideas 
arise  without  effort  and  combine  "  to  form  ingenious  con- 
ceptions, elaborate  resolutions,  vast  projects  which,  alas, 
are  never  likely  to  last  through  the  day";  depressing 
thoughts  disappear  and  life  assumes  a  smiling  aspect. 

This  euphoria  is  identical  with  that  which  is  produced 
by  opium  and  of  which  Thomas  De  Quincey  has  given  such 
an  enthusiastic  description : 

"  O  just,  subtle,  and  all-conquering  opium!  that,  to  the  hearts  of 
rich  and  poor  alike,  for  the  wounds  that  will  never  heal,  and  for  the 
pangs  of  grief  that  '  tempt  the  spirit  to  rebel,'  brings  an  assuaging 
balm; — eloquent  opium  that  with  thy  potent  rhetoric  stealest  away 
the  purposes  of  wrath,  pleadest  effectually  for  relenting  pity, and  through 
one  night's  heavenly  sleep  callest  back  to  the  guilty  man  the  visions 
of  his  infancy,  and  hands  washed  pure  from  blood;  — O  just  and  right- 
eous opium!  that  to  the  chancery  of  dreams  summonest,  for  the  tri- 
umphs of  despairing  innocence,  false  \yitnesses,  and  confoundest  per- 
jury, and  dost  reverse  the  sentences  of  unrighteous  judges; — thou 
buildest  upon  the  bosom  of  darkness,  out  of  the  fantastic  imagery  of 
the  brain,  cities  and  temples,  beyond  the  art  of  Phidias  and  Praxiteles, 
beyond  the  splendours  of  Babylon  and  Hekat6mpylos ;  and,  '  from  the 
anarchy  of  dreaming  sleep,'  callest  into  sunny  light  the  faces  of  long- 
buried  beauties,  and  the  blessed  household  countenances,  cleansed  from 
the  '  dishonours  of  the  grave.'  Thou  only  givest  these  gifts  to  man; 
and  thou  hast  the  keys  of  Paradise,  O  just,  subtle,  and  mighty  opium!  " 


MORPHINISM  359 

Second  Period:  Hesitation. — Many  patients,  conscious 
of  their  danger,  make  efforts  to  escape  from  it.  They 
diminish  the  doses,  reduce  the  number  of  injections,  etc. 
Some  even  completely  discontinue  the  use  of  the  drug 
permanently  or  temporarily. 

The  period  of  hesitation  is  not  constantly  present; 
many  patients  by  reason  of  their  ignorance  or  lack  of  deter- 
mination pass  directly  from  the  first  period  to  the  third. 

Third  Period:  Established  Addiction. — The  poison  has 
now  impressed  its  stamp  upon  the  organism  and  has  estab- 
Ushed  certain  'permanent  symptoms.  Moreover,  its  suppres- 
sion gives  rise  to  a  series  of  characteristic  phenomena,  the 
symptoms  of  abstinence. 

(A)  Permanent  Symptoms. — (a)  Psychic. — These  con- 
sist in  general  reduction  of  psychic  activity,  and  are  mani- 
fested in  the  intellectual  sphere  by  sluggishness  of  association 
and  impairment  of  attention  contrasting  with  intact  orienta- 
tion and  perfect  lucidity,  and  by  retrograde  amnesia  of 
reproduction;  representations  are  in  some  way  inhibited 
but  not  destroyed. 

In  the  emotional  sphere  there  are  indifference  and  atrophy 
of  the  moral  sense.  All  the  aspirations  of  the  patient  reduce 
themselves  to  a  single  idea,  that  of  procuring  morphine  by 
any  possible  means;  disregard  for  conventionalities,  bribery, 
swindling,  falsehoods,  violence,  all  seem  to  him  permissible. 
Many  morphine  addicts  obtain  their  drug  from  the  druggist 
on  false  prescriptions,  others  sell  their  household  articles 
to  purchase  morphine. 

In  the  sphere  of  the  reactions  there  is  generally  marked 
ahoulia.  The  patient  is  conscious  of  the  ruinous  results  of 
his  inactivity,  but  has  not  the  power  to  overcome  it.  This 
symptom  appears  early  and  together  with  the  indifference 
forms  a  characteristic  feature  of  the  mental  state  in  morphine 
and  other  drug  addictions. 

Drug  addicts,  like  criminals,  make  much  use  in  conver- 
sation of  a  special  variety  of  slang,  like  the  expressions  in  the 
following  vocabulary. 


360  DRUG  ADDICTIONS 

Toy,  a  small  jar  of  opium  sold  for  smoking,  constituting  a  sort  of 
standard  of  measure  in  the  illicit  opium  traffic. 

Blowing,  snuffing  heroin. 

Jabbing,  using  heroin,  morphine,  or  cocaine  .^y  hypodermic  m- 
jection. 

Deck  or  Package,  a  portion  containing  one  or  two  doses  sold  for 
snuffing. 

Quill,  a  piece  of  paper  curled  to  be  used  in  snuffing. 

An  eighth,  one  drachm  (an  eighth  of  an  ounce). 

A  quarter-eighth,  half  an  eighth,  two  eighths,  etc.,  derived  from  the 
expression  an  eighth. 

Snow,  cocaine. 

Snow-bird,  cocaine  user,  a  more  or  less  derisive  term  used  by  other 
drug  addicts. 

(6)  Physical. — The  general  nutrition  suffers :  loss  of  flesh, 
pallor  of  the  skin,  etc. 

The  circulatory  apparatus  shows  general  atony.  The 
cardiac  impulse  is  weak;  peripheral  circulation  sluggish; 
there  are  transient  oedemas. 

The  temperature  is  often  subnormal. 

Motility:  general  muscular  asthenia;  a  tendency  to 
fatigue;  tremors:  "  slow,  regular  oscillations  resulting 
from  a  twisting  movement  of  the  limb  upon  itself."  ^ 

Sensibility:  slight  hyperaesthesia  which  is  at  times 
unilateral;  diminution  of  the  acuteness  of  vision,  often 
dependent  upon  ''  pallor  of  the  optic  disc,  which  may  ad- 
vance to  atrophy."  ^ 

The  pupils  are  frequently  myotic. 

The  tendon  reflexes  are  occasionally  diminished. 

In  cases  in  which  the  drug  is  taken  by  hypodermic 
injection  there  are  at  the  sites  of  injection  characteristic 
puncture  points,  spots  of  pigmentation,  indurations,  and  scars 
which  constitute  great  aids  in  diagnosis  in  cases  in  which  a 
trustworthy  history  is  not  to  be  had. 

(B)  Symptoms  of  Abstinence. — When  the  hour  for  his 
injection  has  passed  the  drug  addict  becomes  restless,  his 

1  Jouet.     Quoted  by  Chambard,  loc.  cit. 
^  Pichon.     Le  morphinisme,  1890. 


MORPHINISM  361 

expression  anxious,  respirations  accelerated.  A  state  of 
anxiety  soon  appears,  accompanied  by  marked  inhibition  of 
all  psychic  functions.  The  patient  abandons  his  unfinished 
work  or  conversation  and  leaves,  complaining  that  he  is 
unable  to  bear  the  tortures  of  which  he  is  a  victim.  At 
the  same  time  appear  pathognomonic  somatic  symptoms: 
pallor  of  the  face,  acceleration  and  weakening  of  the  pulse, 
general  prostration,  cold  sweats,  sleeplessness,  abdominal 
cramps,  vomiting  and  spells  of  yawning.  If  abstinence  con- 
tinues the  condition  may  become  alarming:  obstinate 
diarrhoea  appears  and  collapse  is  threatened. 

No  matter  how  grave  the  symptoms  become,  an  injec- 
tion of  morphine  always  affords  instantaneous  relief. 

Occasionally  the  mental  symptoms  present  all  the 
features  of  a  veritable  acute  psychosis:  agitation,  anxiety, 
persecutory  ideas,  psycho-sensory  disorders,  excitement 
simulating  that  of  mania;  these  may  be  associated  with 
hysteriform  or  epileptiform  attacks. 

Fourth  Period:  Cachexia. — The  symptoms  of  the  pre- 
ceding period  become  more  marked.  The  psychic  disag- 
gregation in  some  cases  resembles  true  dementia.  Craving 
for  the  drug  is  greater  than  ever.  Loss  of  flesh  reduces  the 
patient  almost  to  a  skeleton;  the  stomach  rejects  all  food 
and  intractable  diarrhoea  sets  in;  blood  pressure  becomes 
low,  the  cardiac  impulse  grows  weak,  the  pulse  becomes 
small,  thready,  and  irregular;  renal  changes,  which  are 
frequent,  give  rise  to  albuminuria. 

Numerous  complications  are  apt  to  appear,  rendering 
the  prognosis  still  more  serious:  pulmonary  tuberculosis, 
furunculosis,  phlegmons  hasten  the  fatal  termination,  which 
occurs  at  the  end  of  the  fourth  period. 

Treatment. — Its  aim  is  discontinuance  of  the  morphine. 
This  may  be  attained  by  three  methods :  the  sudden  method 
(Levinstein),  the  rapid  method  (Erlenmeyer),  and  the  grad- 
ual method  (the  so-called  French  method). 

The  suppression  of  morphine  or  demorphimzation  cannot 
be  carried  out  outside  of  an  institution  for  the  following 


362  DRUG  ADDICTIONS 

reasons:  (1)  because  the  patient  should  be,  in  case  of  threat- 
ened collapse,  within  immediate  reach  of  medical  aid;  (2) 
because  only  strict  control  can  prevent  the  patient  from 
procuring  the  drug  clandestinely. 

The  method  of  choice  is  rapid  suppression.  "It  is 
a  fact,  recognized  to-day  by  all  physicians  experienced  in 
the  treatment  of  drug  addiction,  that  rapid  suppression  is 
the  best  method  of  treatment."  ^  The  period  of  demorphini- 
zation  lasts  from  five  to  twelve  days.  The  principle  consists 
in  diminishing  the  dose  each  day  by  one-half  of  that  ad- 
ministered on  the  preceding  day,  and  finally,  on  reaching 
a  minute  ration,  completely  suppressing  the  drug.  It  is  in 
the  latter  days  of  the  suppression  that  the  symptoms  of 
abstinence  appear  with  the  greatest  intensity.  Patients 
who  descend  without  much  difficulty  from  1  gram  or  more  to 
several  centigrams  experience  grave  disturbances  when  they 
are  deprived  of  this  minute  allowance. 

Adjuvant  Therapy. — The  diet  should  be  tonic. and  recon- 
structive. In  cases  of  marked  cachexia  it  is  advisable  to 
improve  the  state  of  general  nutrition  before  complete 
demorphinization  .^ 

The  digestive  tract  and  the  heart  demand  special  atten- 
tion. 

Gastro-intestinal  disorders  may  be  prevented  by  the 
use  of  bicarbonate  of  soda  (2-6  grams  daily),  and  cardiac 
failure  by  heart  stimulants,  such  as  caffein,  strophanthus, 
or  digitalis. 

A  morphine  addict  cannot  be  considered  cured  until 
a  long  time  has  elapsed  after  the  suppression  of  the  drug. 
The  return  to  normal  life  is  for  him  a  critical  moment; 
for  this  reason  isolation  in  an  institution  should  be  continued 
for  at  least  several  weeks  after  the  last  injection. 

This  prolonged  detention  is  further  justifiable  by  the 

1  Sollier.  La  demorphinization.  Presse  medicale,  April  23  and 
July  6,  1898. 

'  Joffroy.  Traitement  de  la  morphinomanie.  Gaz.  hebd.  de  M6d. 
et  de  Chirurgie,  1899  and  1900. 


COCAINISM  363 

grave    complications,    notably    fatal    epileptiform    attacks, 
which  may  occur  long  after  complete  demorphinization. 

In  spite  of  all  these  precautions  permanent  cures  are 
the  exception  and  relapses  the  rule. 

Cocaine  addiction  differs  but  little  in  its  general  aspect 
from  either  morphine  or  heroin  addiction.  In  the  course  of 
it,  however,  arises  occasionally  a  special  variety  of  delirium. 

It  is  a  delirium  of  a  painful  character  associated  with 
delusional  interpretations;  its  main  features  consist  in 
psycho-sensory  disorders  which,  in  spite  of  their  extraordinary 
distinctness,  are  coexistent  with  perfect  lucidity.  The  illu- 
sions and  hallucinations  may  affect  all  the  senses,  but  espe- 
cially vision,  touch,  and  the  muscular  sense. 

Objects  change  their  shapes  and  are  constantly  moving. 
A  patient  of  Saury's  ^  felt  himself  assailed  by  a  swarm  of 
bees  which  he  could  see  and  feel.  Patients  feel  worms 
creeping  over  their  bodies  or  coming  out  of  their  flesh; 
they  see  them,  seize  them  with  their  fingers,  and  crush  them 
under  their  feet.  Many  also  perceive  imaginary  movements ; 
the  ground  shakes  beneath  them,  their  bed  is  upset,  or  the 
house  they  are  in,  swept  by  a  flood,  floats  upon  the  waves. 
Hallucinations  of  hearing,  taste,  and  smell,  though  not 
rare,  occur  less  frequently  than  the  preceding  and  pre- 
sent no  special  characteristics. 

Sometimes  the  delusions  assume  the  form  of  morbid 
jealousy,  as  in  alcoholic  psychoses. 

The  reactions  of  the  patient  are  governed  by  the  delusions 
and  are  often  violent. 

The  duration  of  the  attack  is  brief,  several  weeks  at 
the  longest,  and  in  some  cases  but  a  few  days.  We  have 
seen  a  typical  case  of  cocaine  delirium  terminate  in  forty- 
eight  hours. 

The  treatment  consists  in  suppression  of  the  drug,  which 
can  in  the  great  majority  of  cases  be  accomplished  by  the 
rapid  method  without  serious  inconvenience. 

^  Saury.     Cocalnomanie.     Ann.  med.  psych.,  1889. 


CHAPTER  XIII 

SYPHILITIC  DISORDERS 
MESOBLASTIC  INVASION:  CEREBRAL  SYPHILIS 

EARLY  INVOLVEMENT— MENINGITIC  TYPE— GUMMATOUS 
TYPE—ENDARTERITIC  TYPE 

Early  Involvement. — "  Recent  developments  have  shown 
that  the  occurrence  of  syphilis  of  the  central  nervous  system, 
more  particularly  of  the  meninges,  is  much  more  common 
in  the  secondary  stage  than  has  been  generally  recognized, 
and  that  it  may  occur  even  earlier  than  the  secondary 
skin  manifestations.  Various  observers  have  shown  by 
lumbar  puncture  that  in  about  35%  of  all  untreated  cases 
there  is  an  increased  cell  count  and  an  increased  globulin 
content  of  the  cerebro-spinal  fluid,  an  indication  of  syphilitic 
involvement  of  the  meninges.  In  the  early  stages  the  spinal 
fluid  Wassermann  is  -usually  negative.  Early  involvement 
of  the  central  nervous  system  is  frequently  betrayed  by  cer- 
tain complaints  of  the  patient — headache,  neuralgia,  dizzi- 
ness, slight  deafness,  slight  paralysis  of  one  of  the  cranial 


nerves 


"  1 


"  I  believe  that  practically  all  cases  of  neuro-syphilis 
originate  in  the  early  stages  of  the  disease.  This  belief  is 
based  upon  the  results  of  several  hundred  serological  examina- 
tions made  in  the  first  year  of  the  infection.  In  other  words 
the  number  of  cases  of  neuro-syphilis  which  develop  is  not 
greater  than  the  number  of  patients  which  show  positive 
serological  findings  at  this  time.    As  a  corollary  to  this 

1  H.  H.  Young.  Manual  of  Military  Urology.  Published  for  the 
American  Expeditionary  Forces  by  the  American  Red  Cross,  Paris, 
1919. 

364 


CEREBRAL  SYPHILIS  3G5 

statement,  I  further  believe  that  if,  before  a  patient  is  dis- 
charged as  cured,  his  spinal  fluid  is  found  to  be  normal,  he 
will  never  develop  paresis  or  other  forms  of  neuro-syphilis. 
There  is,  of  course,  no  proof  as  yet  available  that  this 
hypothesis  is  correct.  It  will  require  a  good  many  years  of 
observation  before  a  definite  statement  of  this  kind  can  be 
made.  It  is,  however,  a  good  working  hypothesis  and  up  to 
this  time  I  have  never  seen  a  case  of  neuro-syphiHs  develop 
in  a  patient  with  negative  spinal  fluid  after  the  first  or 
second  year  of  his  infection." 

"  When  involvement  of  the  fluid  does  occur  in  the 
secondary  period  of  the  disease  it  is  much  more  amenable  to 
treatment  than  in  old  cases  where  the  infection  has  occurred 
many  years  previously.  I  beheve  that  neuro-syphilis  is 
due  to  a  special  strain  of  spirochete  which  may  have  invaded 
the  fluid  during  the  most  intensive  administration  of  mercury 
and  salvarsan.  In  these  cases  it  is  only  possible  to  reach 
the  infection  by  intraspinal  treatment.  I  have  had  a  num- 
ber of  cases  of  veiy  intense  meningitis  which  developed  a 
few  months  after  infection  shortly  after  the  prolonged  use 
of  salvarsan  and  mercury.  These  patients  are  now  entirely 
cured  both  clinically  and  serologically  by  intraspinal  treat- 
ment." ^ 

Meningitic  Type. — This  type  is  apt  to  occur  compara- 
tively early  in  the  course  of  syphilis,  as  a  rule  within  five 
years  after  the  initial  lesion.  Its  onset  is  usually  rapid, 
the  symptoms  reaching  complete  development  in  two  or  three 
weeks.  Anatomically  it  is  characterized  by  a  subacute 
diffuse  meningeal  inflammation,  most  marked  at  the  base 
or  even  limited  to  that  region,  with  occasional  miliary 
gummata;  the  pial  blood  vessels  are  the  seat  of  more  or  less 
Tvidespread  and  more  or  less  pronounced  endarteritis;  the 
process  may  subside  in  one  area  while  extending  to  another, 
thus  producing  a  peculiarly  vaiying  clinical  picture. 

The  symptoms  are  physical  and  mental.  The  physical 
symptoms,  in  order  of  importance,  are  headache,  dizziness, 

1  J.  H.  Fordyce,  in  a  personal  communication,  dated  May  8,  1918. 


366  SYPHILITIC  DISORDERS 

vomiting,  convulsions,  and  evidences  of  cranial  nerve  in- 
volvement— amaurosis,  ptosis,  strabismus,  facial  neuralgia, 
hypersesthesia  or  anaethesia,  facial  paralysis,  impairment  of 
the  sense  of  smell,   and  possibly  deafness;    the  pupillary 
reaction  to  light  and  distance  may  be  sluggish  or  limited 
in  excursion,   but  the  Argyll-Robertson  sign  is  generally 
absent;  a  spastic  and  partly  paralytic  condition  of  the  lower 
extremities  with  increased  knee  jerks  and  bilateral  or  uni- 
lateral Babinski  sign  is  often  found.     The  mental  symptoms 
are  also  very  important.     "  A  very  characteristic  sign  of 
basic    syphilitic    meningitis    is    the    semi-somnolent,    semi- 
conscious,  semi-comatose  condition,  in  which  the  mental 
functions  are  more  or  less  obfuscated  rather  than  obliterated. 
The  patients  may  present  a  lethargic,  typhoid,  or  semi- 
intoxicated  condition,  from  which  they  can  be  temporarily 
roused — a  condition  which  is,  however,  frequently  combined 
with  a  purposeless,  hazy  motor  dehrium,  not  of  a  purely 
automatic  character.     Even  in  the  lesser  degrees  of  obnubi- 
lation of  consciousness,  there  are  certain  criteria  of  special 
significance;   thus  a  patient  may  be  roused  to  more  or  less 
correctly  answer  questions  in  a  slow,  drawling,  dreamy,  sleepy 
manner.     He  may  even  perform  complex  acts  in  response 
to  requests  or  demands,  yet  be  unable  to  respond  to  the  calls 
of  nature,  and  he  passes  urine  and    faeces  in  the  bed,  or 
evacuates  his  excreta  in  the  room.     Occasionally  the  patient 
may  shamelessly  masturbate.     The  mind  may  again  become 
clear  and  he  may  regain  control,  but  not  infrequently  this 
loss  of  control  over  the  sphincters  persists,  and  this  denotes 
usually  a  permanent  state  of  dementia.     The  dementia  of 
syphiUtic  brain  disease  is  characterized  by  being  partial  and 
recurring  in  attacks;    it  does  not  alter  the  character  and 
personality  of  the  individual  to  the  same  extent  as  in  the 
dementia  of  general  paresis.     He  preserves  his  autocritical 
faculties  and  is  conscious  of  his  intellectual  deficit,  and  he  is 
by  no  means  indifferent  to  his  mental  and  bodily  condition. 
He  may  suffer  with  loss  of  memory,  especially  of  recent 
events,  and  his  knowledge  of  time  and  place  may  be  defective. 


CEREBRAL  SYPHILIS  367 

He  is  subject  to  sudden  fits  of  excitation  with  motor  rest- 
lessness or  of  depression  with  suicidal  tendencies."  ^ 

Gummatous  Type. — This  type  is  comparatively  infre- 
quent. It  is  characterized  anatomically  by  the  presence  of 
one  or  more  large  gummata  originating  in  the  meninges  and 
extending  into  the  brain  substance.  The  physical  symptoms 
are  apt  to  be  those  of  brain  tumor  together  with  hemianopsia, 
aphasia,  convulsions,  hemiplegia,  etc.,  according  to  the 
location  of  the  gummata.  The  mental  symptoms  are  much 
like  those  of  the  diffuse  meningitic  type. 

Endarteritic  Type. — This  is  perhaps  the  commonest 
type  of  cerebral  syphilis,  especially  if  we  take  account  of  the 
circumstance  that  many  cases  are  dijSicult  to  distinguish 
from  cerebral  arteriosclerosis  and  are  often  classified  as  such. 
The  clinical  manifestations  are,  in  fact,  essentially  those  of 
cerebral  arteriosclerosis.  Even  post  mortem  the  differentia- 
tion cannot  always  be  made  with  certainty;  the  characteris- 
tic finding  in  cerebral  syphilis  is  a  proliferative  endarteritis 
accompanied  by  more  or  less  marked  lymphoid  and  plasma- 
cell  infiltration  of  the  adventitial  sheaths  and,  perhaps, 
patches  of  similar  infiltration  in  the  pia. 

Various  combination-forms  of  the  three  above-mentioned 
types  of  cerebral  syphilis  are  found  in  practice. 

Diagnosis.— Cerebral  syphilis  often  has  to  be  differen- 
tiated from  brain  tumor,  general  paralysis,  and  cerebral 
arteriosclerosis. 

In  cases  of  brain  tumor  the  presence  of  the  cardinal 
symptoms  and  focal  symptoms  and  the  absence  of  lympho- 
cytosis in  the  cerebro-spinal  fluid  and  of  the  Wassermann 
reaction  both  in  the  blood  and  in  the  fluid  will  exclude  cere- 
bral syphilis. 

When  the  clinical  differentiation  from  general  paralysis 
is  uncertain,  some  help  may  be  gained  from  an  examination 
of  the   cerebro-spinal   fluid;    the  Wassermann   reaction   is 

^  F.  W.  Mott.  Syphilis  of  the  Nervous  System.  A  System  of 
Syphilis,  edited  by  D'Arcy  Power  and  J.  K.  Murphy,  Vol.  IV.  London, 
1910. 


368  SYPHILITIC  DISORDERS 

positive  in  from  75  to  90%  of  cases  of  general  paralysis 
and  in  but  30  or  35%  of  cases  of  cerebral  syphilis;^  in  the 
latter  condition  it  is  most  apt  to  be  positive  in  cases  of  the 
meningitic  type  and  negative  almost  as  a  rule  in  the  gum- 
matous and  endarteritic  types;  lymphocytosis  is  almost 
invariably  present  in  general  paralysis,  the  usual  finding 
being  from  15  to  50  cells  per  cubic  millimeter,  while  in  cere- 
bral syphilis  it  is  inconstant  and  extremely  variable  in  degree, 
being  very  often  slight  or  absent  in  the  gummatous  and  en- 
darteritic types  and  as  a  rule  extremely  marked  in  the 
meningitic  type — from  100  to  1500  cells  or  more  per  cubic 
millimeter  ;2  the  typical  reaction  obtained  in  the  colloidal 
gold  test  in  ca^es  of  general  paralysis  is  not  apt  to  be  obtained 
in  cerebral  syphilis,  there  being,  instead,  as  a  rule,  but  a 
slightly  marked  precipitation  in  the  first  one  or  two  tubes, 
a  mere  change  of  color  in  the  next  two  or  three,  a  more 
intense  reaction  again  in  the  next  one,  two,  or  three  tubes, 
and  no  change  at  all  in  the  remaining  ones — 3321122200.^ 

The  test  of  treatment  is  of  value  in  many  cases,  im- 
provement or  recovery  under  salvarsan  or  mercury  and 
iodides  with  reduction  or  disappearance  of  the  lymphocytosis 
indicating  cerebral  syphilis  and  not  general  paralysis. 

In  cerebral  arteriosclerosis  the  findings  in  the  cerebro- 
spinal fluid  are  negative,  so  that  a  difficulty  in  differentia- 
tion arises  only  in  connection  with  those  cases  of  the  endar- 
teritic type  of  cerebral  syphilis  in  which  the  findings  are 
likewise  negative,  and  in  such  cases,  as  already  stated,  the 
differentiation  cannot  always  be  made  with  certainty  even 
post  mortem.  A  history  of  syphilitic  infection  will,  naturally, 
turn  the  probability  toward  cerebral  syphilis.  The  age 
of  the  patient  may  help  in  the  differentiation :  cases  occurring 
in   persons  under  forty-five   are  almost  surely  syphilitic; 

1  D.  M.  Kaplan.  Serology  of  Nervous  and  Mental  Diseases.  Phila- 
delphia and  London,  1914,  p.  19L 

2  D.  M.  Kaplan.     Loc.  cit.,  p.  157. 

^  Swalm  and  Mann.  The  Colloidal  Gold  Test  on  Spinal  Fluid  in 
Paresis  and  Other  Mental  Diseases.    N.  Y.  Med.  Journ.,  Apr.  10,  1915. 


CEREBRAL  SYPHILIS  369 

in  persons  between  forty-five  and  sixty  the  probability  is 
still  strongly  in  favor  of  syphilis ;  after  sixty  this  probability 
diminishes  with  advancing  senility. 

Prognosis. — Cerebral  syphilis  is  a  grave  affection;  un- 
treated cases  progress  more  or  less  rapidly  with  tissue 
destruction  and  often  a  fatal  termination.  Treatment, 
however,  if  instituted  early  may  result  in  a  quick  and  per- 
fect cure;  the  most  favorable  cases  from  this  point  of  view 
are  those  of  the  meningitic  type;  cases  of  the  gummatous 
type  are  often  stubbornly  resistant  to  treatment;  in  most 
cases  of  the  endarteritic  type  recovery  cannot  be  expected 
owing  to  the  tissue  destruction  which  occurs  quickly,  but 
much  improvement  may  result  from  prompt  and  vigorous 
treatment. 


CHAPTER  XIV 

SYPHILITIC  DISORDERS  (Continued) 
PARENCHYMATOUS  INVASION:    GENERAL  PARALYSIS 

Synonyms.- — Chronic  arachnitis  and  chronic  meningitis  (Bayle). 
Incomplete  general  paralysis  (Delaye).  General  paralysis  of  the 
insane  or  chronic  diffuse  periencephalo-meningitis  (Calmiel).  Para- 
\yiic  insanity  (Parchappe).  Progressive  general  paralysis  (Lunier, 
Sadras).  Paralytic  dementia  (Baillarger) .  Chronic  diffuse  inter- 
stitial encephahtis  (Magnan).  In  German:  Progressive  allgemeine 
Paralyse.  In  general  it  is  convenient  to  employ  the  Latin  term  dementia 
paralytica. 

The  earliest  mention  of  the  somatic  and  psychic  dis- 
orders corresponding  to  general  paralysis  dates  back  to 
1798,  when  Haslam,  pharmacist  at  the  Bethlehem  Hospital, 
described  in  a  few  Unes  and  with  remarkable  precision  the 
principal  features  of  the  disease. 

It  was  only  in  1822,  thanks  to  the  memorable  work 
of  Bayle,  that  general  paralysis  gained  a  footing  in  classical 
psychiati'y.  The  history  of  this  disease  is  a  subject  much 
too  vast  for  the  hmits  of  this  work.  It  has  been  quite 
thoroughly  treated  by  Vignaud  ^  in  his  inaugural  thesis, 
which  contains  also  a  good  bibliography .^ 

1  Histoire  de  la  paralysie  generate.     Paris.     These. 

^Monographs  on  general  paralysis:  Lasegue.  De  la  paralysie 
generate  progressive.  Th.  d'agreg.  Paris,  1853;  also  Legons  sur  la 
paralysie  generate,  1883. — Falret.  Recherches  sur  la  fotie  paralytique 
et  les  diverses  paralysies.  Paris,  1853. — Voisin.  Traite  de  la  paralysie 
generate.  1879. — BaOlarger.  Theorie  de  la  paralysie  generate.  Ann. 
med.  psych.,  1883 — Mendel.  Die  progressive  allgemeine  Paralyse 
der  Irren,  1880. — Mairet  et  Vires.  De  la  paralysie  generate.  Etiologie. 
Pathogenic.    Traitement,     1893. — Magnan  et  Serieux.    La  paralysie 

370 


GENERAL  PARALYSIS  371 

Prodromal  Period. — It  is  marked  (a)  by  changes  of 
affectivity  and  character;  (6)  by  neurasthenic  and  psychas- 
thenic phenomena. 

(a)  The  mood  becomes  either  irritable  and  changeable, 
with  sudden  alternations  of  joy  and  sorrow,  kindness  and 
anger,  discouragement  and  optimism;  or  gloomy  and 
marked  by  pessimism  and  by  a  tcedium  vitce  which  may  lead 
the  patient  to  attempts  of  suicide.  Often  the  patient  is 
conscious  of  being  stricken  with  a  grave  disease  and  has  dark 
presentiments  for  the  future. 

(6)  The  neurasthenic  and  psychasthenic  symptoms  are 
usually  very  pronounced:  a  feeling  of  general  lassitude, 
fatigue,  muscular  weakness,  diffuse  neuralgic  pains,  head- 
ache, a  sort  of  grinding  sensation  felt  especially  in  the  head, 
and  other  peculiar  sensations  which  the  patient  is  unable  to 
describe  clearly:  it  may  seem  to  him  that  his  head  is  empty, 
that  his  brain  is  falling  to  pieces,  etc. 

These  symptoms  are,  however,  not  identical  with  those 
of  true  neurasthenia.  The  following  are,  according  to 
Ballet,  the  most  important  points  of  difference: 

"  (1)  The  stigmata,  that  is  to  say,  the  permanent  signs 
of  neurasthenia  (helmet  sensation,  pain  in  the  spine),  are 
usually  absent. 

"  (2)  Neuralgic  pains  occupy  a  prominent  place  in  the 
clinical  picture.  These  pains  (excluding  the  lightning  or 
lancinating  pains  dependent  upon  spinal  lesions)  are  dis- 
seminated, essentially  mobile,  varying  from  day  to  day. 
The  patients  often  speak  of  them  as  '  pains  that  are  peculiar, 
unusual.' 

"  (3)  From  one  moment  to  another  sudden  changes 
are  produced  in  the  state  of  the  patient.  ...  It  is  surprising 

■generale  (collection  Leaute),  1894. — Coulon.  Considerations  sur  la 
nature  de  la  paralysie  generale. — Klippel.  Les  paralysies  generates. 
L'oeuvre  medico-chirurgicale,  1898. — For  a  bibliography  of  general 
paralysis,  see  G.  Ballet  and  J.  Rogues  de  Fursac.  Article- Paralysie 
Generale  in  Traite  de  Medecine  Charcot-Bouchard-Brissaud.  Paris, 
1905. — E.  Kraepelin.  General  Paresis.  Eng.  trans,  by  J.  Moore. 
Nerv.  and  Ment.  Dis.  Monograph  Series.     New  York,  1914. 


372  SYPHILITIC  DISORDERS 

to  see  the  neurasthenic  paretic,  who  but  a  short  time  before 
complained  of  severe  suffering  and  ill  health,  forget  his  pains 
under  the  influence  of  some  incident  or  conversation  in  which 
he  is  interested  and  in  which  he  takes  an  active  part.  These 
momentary  changes,  appearing  at  the  instance  of  chance 
occurrences,  may  manifest  themselves  in  a  more  lasting 
manner  on  instituting  some  treatment,  though  insignificant. 
The  patient,  hitherto  excessively  discouraged  and  gloomy, 
speaks  with  joy  of  his  cure;  his  satisfaction  is  exuberant  and 
out  of  proportion,  as  was  his  despair  shortly  before." 

Often  some  transient  phenomenon,  exceptional  or  un- 
known in  neurasthenia,  alarms  the  physician :  slight  seizures, 
transitory  strabismus  with  diplopia,  slightly  marked  mo- 
mentary disorders  of  speech. 

The  period  of  prodromata  is  seldom  absent.  It  is  often 
long,  lasting  several  months  or  years. 

§  1.    Essential  Symptoms 

It  will  be  necessary  to  consider  these  apart  from  accessory 
and  inconstant  symptoms,  by  the  presence  of  which  they 
are  often  masked. 

The  essential  symptoms  are: 

(A)  Mental  deterioration; 

(B)  Disorders  of  motility; 

(C)  Pupillary  disturbances; 

(D)  Changes  in  general  nutrition. 

(A)  Mental  Deterioration. — It  presents  two  fundamental 
characteristics: 

(1)  It  affects  all  the  psychic  functions  in  their  ensemble; 

(2)  It  is  progressive,  and  usually  rapidly  so.  This  latter 
characteristic  distinguishes  paralytic  dementia  from  senile 
dementia,  the  development  of  which  is  much  slower. 

Let  us  analyze  rapidly  the  elements  constituting  this 
mental  deterioration. 

(a)  Memory. — It  is  profoundly  affected  from  the  begin- 
ning.    The  amnesia  is  both  anterograde,  by  default  of  fixation, 


GENERAL  PARALYSIS  873 

and  retrograde,  by  destruction  of  impressions.  It  is  essen- 
tially incurable. 

The  disappearance  of  old  impressions  probably  follows 
the  law  of  amnesia;  but  its  course  is  so  rapid  that  it  is 
difficult  to  demonstrate  this  fact.  The  impressions  of 
youth  and  childhood  become  very  rapidly  effaced,  so  that 
after  a  relatively  short  period  only  a  few  confused  and 
distorted  recollections  remain  in  the  mind  of  the  patient, 
and  these  are  only  with  great  difi&culty  recovered  from  the 
general  wreck. 

(6)  Consciousness  and  Perception. — Their  disorders  are 
manifested  by: 

(I)  More  or  less  complete  loss  of  orientation  in  all  its 
forms; 

(II)  More  or  less  confused  perception  of  the  external 
world. 

The  clouding  of  consciousness  and  the  confusion  attain 
in  the  terminal  period,  and  in  certain  forms  in  the  beginning, 
an  extreme  intensity. 

(c)  Attention  and  Association  of  Ideas. — The  attention 
of  the  patient  is  difficult  to  rouse  as  well  as  to  fix.  In  some 
cases  early  in  the  disease,  in  phases  of  excitement,  there 
may  be  flight  of  ideas.  This,  however,  is  of  exceptional 
occurrence;  as  a  rule  there  is  sluggish  formation  of  associa- 
tions of  ideas  demonstrable  by  psychometry  or  by  an  ordinary 
clinical  examination.  In  the  cases  in  which  some  mental 
activity  is  still  possible  there  is  rapid  mental  fatigability,  so 
that  the  patient  is  no  longer  able  to  do  mental  work  of  any 
complexity;  in  advanced  stages  even  the  simplest  intellectual 
operations  are  impossible. 

(d)  Affectiinty. — Its  changes  are  characterized  by  morbid 
indifference  and  irritability,  associated  in  the  manner  already 
described.^  Both  the  indifference  and  the  irritability  are 
apt  to  be  very  marked.  The  general  paralytic  takes  no 
interegt  in  his  own  business  or  in  the  welfare  of  his  relatives. 

1  See  Part  I,  Chapter  IV. 


374  SYPHILITIC  DISORDERS 

Grave  occurrences  fail  to  impress  him.  On  the  other  hand, 
he  is  subject  to  fits  of  terrible  anger  on  the  slightest  provo- 
cation. 

The  moral  sense  and  regard  for  conventionalities  disappear 
entirely.  The  patient  commits  the  most  ridiculous  and  most 
revolting  acts  with  perfect  serenity  and  is  astonished  when  his 
liberty  of  action  is  interfered  with. 

(e)  Judgment. — Its  disorder  finds  expression  in  the 
patient's  total  lack  of  insight  into  his  condition.  Together 
with  the  amnesia,  it  explains  the  inconsistencies  in  the 
patient's  conduct  and  speech;  he  is  unable  to  appreciate 
the  most  flagrant  contradictions.  To  a  given  question  he 
gives  the  first  answer  that  enters  his  mind,  whether  it  happens 
to  be  false  or  correct,  absurd  or  plausible. 

(/)  Reactions. — As  might  be  expected,  they  are  always 
impulsive.  The  reflections,  that  is  to  say  the  series,  of 
associations  preceding  the  act,  become  more  and  more 
reduced.  As  the  patient  sees  what  he  wants  he  immediately 
takes  it.  He  wants  an  object  that  he  sees  exposed  for  sale 
in  a  shop — he  takes  it  and  carries  it  off  without  taking  the 
trouble  to  pay  for  it.  A  paralytic  leaning  over  the  parapet 
of  a  bridge  drops  his  cane.  To  recover  it,  reasoning  that  a 
straight  Hue  is  the  shortest  distance  between  two  points, 
he  jumps  after  it  into  the  water.  Stereotyped  movements 
(movements  of  sucking,  grinding  the  teeth,  etc.)  and  nega- 
tivism are  frequent.  Cataleptoid  attitudes  are  occasionally 
seen. 

(B)  Motor  Disturbances. — The  fundamental  motor  dis- 
turbances, the  only  ones  that  need  occupy  us  here,  are  three 
in  number:  (a)  Progressive  muscular  weakness;  (6)  Tremors; 
(c)  Motor  incoordination. 

(a)  Muscular  Weakness. — It  is  most  marked  in  the 
latter  periods  of  the  affection,  when  it  accompanies  the 
general  cachexia.  It  involves  all  the  muscles  and  is  asso- 
ciated with  more  or  less  pronounced  atrophy  so  that  there 
is  more  or  less  complete  disability. 

(6)   Tremors. — Unlike    the    muscular    weakness,    these 


GENERAL  PARALYSIS  375 

constitute   an   early   symptom.     They   are   of  two   kinds: 
fibrillary  tremors  and  tremors  en  masse. 

(I)  The  fibrillary  tremors  consist  in  rapidly  repeated 
contractions  of  very  small  groups  of  muscular  fibers.  It  is  a 
sort  of  twitching.  It  is  observed  chiefly  in  the  tongue  and  in 
the  peri-buccal  muscles. 

(II)  Tremors  en  masse  usually  appear  as  coarse  oscil- 
lations, irregular  in  frequency  and  in  amplitude.  They 
become  evident  on  voluntary  movements  and  form  a  sort 
of  point  of  transition  between  true  tremors  and  muscular 
ataxia.  They  are  seen  especially  in  the  upper  extremities 
and  in  the  tongue.  The  tongue  projected  from  the  mouth 
executes  to-and-fro  movements  very  aptly  described  by 
Magnan  as  "  trombone  movements." 

(c)  Motor  Incoordination. — This  first  becomes  evident 
in  the  most  delicate  movements  and  manifests  itself  early 
by  impairment  of  speech  and  handwriting. 

I.  The  impairment  of  speech,  clearly  apparent  in  advanced 
stages,  is  sometimes  difficult  to  notice  at  the  beginning  and 
becomes  evident  only  on  resorting  to  special  tests,  such  as 
prolonged  reading  in  a  loud  voice  or  the  pronunciation  of 
test-phrases:  Methodist  Episcopal,  fourth  cavalry  brigade, 
national  intelligence,  etc. 

Sometimes  the  impairment  of  speech  becomes  less  evident 
or  even  disappears  temporarily  during  excitement.  Often 
it  becomes  accentuated  after  apoplectiform  or  epileptiform 
attacks. 

It  is  of  various  types,  the  principal  of  which  are  the 
following: 

(a)  Drawling,  tremulous,  indistinct  speech; 

(6)  Scanning  speech  analogous  to  that  of  disseminated 
sclerosis; 

(7)  Hesitating  speech:  the  patient  stops  in  the  middle 
of  a  word  and  seems  to  hesitate  before  finishing  it; 

(5)  Omission  of  one  or  more  syllables:  the.  patient 
pronounces,  for  instance,  "  Methist  Pispal "  instead  of 
Methodist  Episcopal; 


376  SYPHILITIC  DISORDERS 

(e)  Reduplication  of  one  or  of  several  sj^llables,  as 
"  constititutional ''; 

(f)  Interchange  of  sj^llables:  "  constutitional." 

These  types  may  be  combined  so  as  to  form  mixed 
types  of  infinite  variet\\ 

II.  The  handuriting  is  characterized  by  its  irregular 
appearance,  and  by  the  coarse  tremors  seen  in  the  strokes. 
These  motor  disorders  are  always  associated  with  phenomena 
of  intellectual  origin :  omissions,  or,  on  the  contrary,  repeti- 
tions of  letters,  syllables,  or  words,  numerous  glaruig  ortho- 
graphical errors.  All  these  features  impart  to  the  hand- 
writing of  general  paralysis  its  characteristic  aspect. 

Usually  the  patient  is  totally  unconscious  of  these 
sj-mptoms.  If  accidentally  he  notices  them,  he  is  neither 
surprised  nor  alarmed.  The  explanations  which  he  gives 
are  childish:  he  does  not  speak  weU  because  he  has  lost  a 
tooth,  or  he  writes  with  difficulty  because  his  hands  are  cold. 

SUght  m  the  beginning,  the  impediment  of  speech  and 
the  impairment  of  handwriting  become  progressively  aggra- 
vated, so  that  in  the  terminal  stage  of  the  disease  the  ^^Titing 
becomes  shapeless  scribbling  and  the  speech  unintelKgible 
stammering. 

At  the  end  of  the  disease  it  is  almost  constant  to  note 
'disturbanoe  of  deglutition  caused  bj^  paresis  and  incoordi- 
nation of  the  pharjmgeal  muscles,  which  may  entaU  death 
by  suffocation. 

(C)  PupUlary  Disorders.^ — These  appear  sometimes  very 
early. 

Thej'  are  dependent  upon  an  internal  ophthahnoplegia  of 
gradual  and  progressive  development  (Baillet  and  Bloch), 
which  is  manifested  by  changes  in  the  shape,-  size,  and  reac- 
tions of  the  pupil. 

(a)  Changes  in  Shape. — The  pupil  loses  its  circular 
shape  and  becomes  oval  or  irregular.  This  sjTuptom  seems 
to  be  frequent,  but  of  its  diagnostic  value  httle  is  known. 

^  Mignot.  Contribution  a  Vetude  des  troubles  pupillaires  dans  quel- 
quss  maladies  mentales.     These  de  Paris,  1900. 


GENERAL  PARALYSIS  377 

(6)  Changes  in  Size. — These  are  of  three  kinds: 

I.  Myosis,  at  times  so  marked  that  the  pupils  are  reduced 
to  pin-hole  size. 

II.  Mydriasis,  also  very  weU  marked  in  some  cases. 

III.  Inequality,  which  may  be  produced  by  three  different 
mechanisms : 

(a)  One  pupil  is  normal,  the  other  myotic  or  mydriatic; 
(iS)  One  pupil  is  mydriatic,  the  other  myotic; 

(7)  Both  pupils  are  mydriatic  or  myotic,  but  are  un- 
equally dilated  or  contracted. 

It  is  important,  in  order  to  make  a  satisfactory  examina- 
tion of  the  pupils,  to  place  the  patient  in  such  a  light  that 
both  eyes  receive  an  equal  amount  of  illumination.  It  is 
also  important  to  vary  the  intensity  of  illumination,  because 
an  inequality  that  appears  doubtful  in  a  strong  light  may 
become  very  evident  ui  a  weaker  light,  and  vice  versa. 

Pupillary  inequality  is  sometimes  congenital.  More- 
over, it  is  encountered  in  many  affections  other  than  general 
paralysis :  dementia  prsecox,  compression  of  the  sympathetic 
nerve,  etc.;  therefore,  it  does  not  by  any  means  constitute 
a  pathognomonic  sign. 

(c)  Changes  in  the  Reflexes. — These  consist  in  changes 
in  the  light  reflex,  or  the  accommodation  reflex,  or  both.  They 
are  either  binocular  or  monocular. 

Disorders  of  the  pupillary  reactions  may  be  associated 
as  in  the  Argyll-Robertson  type:  abolition  of  the  light 
reflex  with  persistence  of  the  accommodation  reflex.  This 
combination  is,  however,  considerably  less  frequent  in 
general  paralysis  than  in  tabes. 

i      At  the  beginning  of  the  disease  the  reactions  are  not 
completely  abolished,  but  are  simply  paretic. 

It  is  not  uncommon  for  the  speech  defect  and  the  pupil- 
lary signs  to  persist  through  complete  mental  remissions. 

(D)  Changes  in  General  Nutrition. — Though  constant 
and  very  important  they  have  thus  far  received  but  little 
attention.  Clinically  we  find  changes  in  weight  and  in  the 
urinary  secretion. 


378  SYPHILITIC  DISORDERS 

The  onset  is  almost  always  marked  by  considerable  loss 
of  weight.     Later  the  weight  varies  with  the  clinical  form. 

In  the  excited  and  depressed  forms  of  rapid  evolution 
the  loss  of  weight  is  marked  and  progressive,  and  the  patient 
rapidly  becomes  cachectic. 

In  the  expansive  or  demented  forms  the  weight  often 
rises  after  the  initial  fall,  the  patient  then  becoming  cor- 
pulent and  remaining  so  until  the  terminal  stage,  when  the 
weight  may  fall  suddenly  and  continue  to  drop  as  marasmus 
is  established. 

Organic  crises  may  be  noted  in  the  course  of  the  disease 
(Arnaud);  they  consist  in  transitory  but  considerable  loss 
of  weight,  the  cause  of  which  is  unknown. 

The  changes  in  the  urinary  secretion  indicate  general 
sluggishness  of  nutrition.  They  have  been  especially 
studied  in  connection  with  the  second  period  of  the  disease. 
The  principal  ones  are  polyuria,  low  specific  gravity  of  the 
urine,  slight  albuminuria,  very  considerable  diminution  of 
urea  and  of  phosphates,  and  increase  of  chlorides.^ 

A  study  of  the  blood  changes  might  also  be  of  great 
interest.  The  work  already  done  along  this  line  is  unfor- 
tunately very  scant  and  inconclusive.  Capps  ^  found  a  slight 
diminution  of  haemoglobin  and  of  the  red  blood  cells. 

§  2.    Inconstant  Symptoms 

Many  symptoms,  though   not   constant  are,  however, 
frequent  and  important. 
This  group  comprises: 

(A)  Mental  disorders; 

(B)  Motor  disorders; 

(C)  Disorders  of  the  reflexes; 

(D)  Disorders  of  sensation; 

^  Klippel  et  Serveaux.  Contribution  a  V etude  de  I'urine  dans  la 
paralysie  generale.  Congres  des  m^dicins  alienistes  et  neurologistes, 
1895. 

2  American  Journ.  of  the  Med.  Sc,  1896,  No.  290. 


GENERAL  PARALYSIS  379 

(E)  Trophic  disorders; 

(F)  Visceral  disorders; 

(G)  Epileptiform  and  apoplectiform  seizures. 

(A)  Mental  Disorders. — The  principal  are  delusions 
and  hallucinations. 

(a)  The  delusions  of  the  general  paralytic  are  of  the 
demented  type;  that  is  to  say,  they  are  absurd,  mobile, 
multiple,  and  contradictory. 

They  assume  all  forms; 

(a)  Ideas  of  grandeur:  the  patient  is  immensely  rich; 
milHons  are  not  adequate,  the  general  paralytic  counts  his 
riches  by  trillions;  he  governs  the  forces  of  nature,  resusci- 
tates the  dead,  is  the  incarnation  of  all  the  great  men  of  the 
present  and  of  the  future,  destroys  and  reconstructs  the 
universe  by  a  single  gesture,  etc. 

((3)  Melancholy  ideas:  ideas  of  culpability:  one  patient 
accused  himself  of  having  hastened  the  end  of  the  world 
by  ten  thousand  centuries;  hypochondriacal  ideas:  another 
patient  refused  to  eat  because  he  had  "  a  bicycle  manufac- 
tory in  the  throat";  ideas  of  negation:  the  organs  are 
liquefied  or  replaced  by  air,  the  body  is  nothing  but  a  putre- 
fied corpse;  ideas  of  ruin  analogous  to  those  of  melancholia. 

(7)  Persecutory  ideas:  they  are  either  primary  or  second- 
ary to  ideas  of  grandeur.  In  the  latter  case  the  patients 
complain  that  they  have  been  robbed  of  their  immense 
fortune,  that  they  are  not  treated  with  the  respect  to  which 
they  are  entitled,  that  they  are  unjustly  detained  in  the 
institution,  etc.  Occasionally  at  the  beginning  persecutory 
ideas  become  systematized,^  but  always  imperfectly.  A 
close  examination  always  reveals  certain  flagrant  contradic- 
tions by  which  the  mental  deterioration,  manifests  itself. 

(6)  The  frequency  of  hallucinations  in  general  paralysis 
is  a  much  disputed  question.  Some  authors  believe  that  they 
are  almost  constant  (Christian  and  Ritti) ,  or  at  least  frequent 
(Wernicke);    others  claim  that   they  are  rare    (Magnan, 

^  Magnan.     Legons  diniques. 


380  SYPHILITIC  DISORDERS 

Dagonet,  Krafft-Ebing) .  The  latter  opinion  is  the  more 
widely  accepted  and  I  believe  the  more  correct  one. 

The  hallucinations  may  affect  any  of  the  senses,  including 
the  muscular  sense. 

Illusions  are  much  more  frequent  than  hallucinations. 

Psycho-sensory  disorders  are  encountered  chiefly  in  the 
excited  form  of  general  paralysis,  in  which  they  are  associated 
with  incoherent  delusions. 

The  systematized  persecutory  delusions  which  are  oc- 
casionally met  with  are  apt  to  be  associated  with  auditory 
hallucinations. 

As  in  all  cases  of  pronounced  dementia,  the  reactions  and 
the  emotional  tone  do  not  always  harmonize  with  the 
delusions.  A  general  paralytic  who  believes  himself  to  be 
dead  may  eat  heartily  and  remain  otherwise  unaffected. 

The  following  case  illustrates  the  type  of  delusions  in 
general  paralysis: 

Marie  B.,  thirty-two  years  old,  cafe  singer. — Family  history  un- 
known.— Patient  occasionally  drinks  to  excess.  Syphilis  very  probable, 
as  patient  has  lived  for  some  years  with  a  man  who  had  syphilis.  She 
had  two  still-births.- — She  was  arrested  for  creating  a  disturbance  on  a 
public  thoroughfare  and  was  sent  to  the  Clermont  Asylum.  On  the 
way  to  the  asylum  she  was  greatly  excited,  spoke  of  her  immense 
fortune,  distributing  millions  among  those  about  her,  made  indecent 
signs  to  all  the  men  she  met,  but  submitted  readily  to  being  taken  to 
the  asylum. 

Two  days  after  her  arrival  at  the  asylum,  at  the  time  that  this 
record  was  made,  the  patient  showed  marked  excitement.  Her  face 
was  red,  her  eyes  sparkling.  She  was  very  voluble,  yet  quite  tractable. 
Her  orientation  was  very  imperfect,  delusions  extremely  active.  She 
said  that  she  was  in  a  town  called  Clermont,  and  that  she  had  been 
there  three  months;  that  it  was  the  spring  of  1894  (in  reality  March, 
1904);  that  the  institution  she  was  in  was  a  hospital  for  wounded 
soldiers.  It  was  pointed  out  to  her  that  there  were  no  soldiers  there. 
"  That  is  true,"  she  said,  "  they  are  in  Nice.  I  take  good  care  of  them. 
I  do  not  put  them  in  a  dungeon,  but  in  a  beautiful  room."  She  knew 
at  once  that  there  were  insane  patients  in  the  asylum,  but  there  are 
no  longer  to  be  any  there,  as  to-morrow  she  is  going  to  cure  them  all 
with  a  good  cathartic.  She  had  already  cured  her  husband  "  of  a  filthy 
disease  by  cleaning  out  his  bowels."     This  husband  of  hers  married  the 


GENERAL  PARALYSIS  381 

daughter  of  a  colonel  who  left  him  two  days  after  the  wedding.  The 
patient  states  that  she  herself  had  also  been  sick;  she  was  operated  on 
by  Duchess  de  C,  then  went  for  six  months  without  making  water 
or  moving  her  bowels,  but  she  was  never  sick  enough  to  go  to  bed,  neither 
were  her  horses.  She  has  ten  thousand  race  horses  that  can  make 
twelve  hundred  miles  an  hour  without  getting  out  of  breath.  The 
proof  is  that  they  went  from  Paris  to  Marseilles  in  four  and  a  half  hours. 
She  is  very  wealthy,  she  has  a  million  francs.  When  it  was  pointed 
out  to  her  that  a  million  is  not  so  much,  she  said  she  had  made  a  mistake 
she  should  have  said  thirty  million  francs.  At  any  rate  it  is  going  to 
be  increased  to  one  hundred  and  fifty  million  this  week.  All  this  for- 
tune came  to  her  by  inheritance.  She  also  has  several  hundred  mansions 
which  she  will  convert  into  hospitals.  Everybody  around  her  shall  be 
happy.  The  nurse  who  is  taking  care  of  her  shall  receive  a  hospital, 
a  mansion,  three  broughams,  a  landau,  two  thoroughbred  horses,  male 
and  female,  so  that  they  may  have  young  ones,  a  race  track,  an  angora 
cat,  and  an  estate  with  cultivated  grounds.  Another  patient  struck 
her  without  provocation;  "  That's  nothing!  She  shall  have  her  little 
million  like  everybody  else,  just  the  same,  also  a  suit  of  man's  clothes 
in  which  she  can  follow  the  regiments." — She  has  two  boys,  "  each 
twenty  years  old  ";  she  herself  is  twenty-five  years  old.  She  had  her 
first  child  at  the  age  of  twelve.  She  states  that  she  drinks  a  good 
deal.  In  aU  the  towns  through  which  she  passed  the  station-masters  and 
those  in  charge  of  provisions  gave  her  the  key  to  their  wine  cellar  in 
order  that  she  might  help  herself  at  her  pleasure.  When  asked  whether 
she  could  drink  ten  quarts  of  wine  a  day,  she  exclaimed:  "  Ten  quarts! 
a  good  deal  more,  at  least  a  barrelful,  for  I  drink  a  quart  with  every 
meal."  Her  memory  is  greatly  impaired;  what  little  correct  informa- 
tion the  patient  gives  is  lost  in  the  multitude  of  disconnected  pseudo- 
reminiscences. — Physical  signs:  Distinct  speech  defect  shown  in  her 
spontaneous  utterances  as  well  as  by  test  words.  The  pupils  show  scarcely 
any  reaction  to  light;  they  react  to  accommodation  readUy.  Marked 
hyperaesthesia  over  entire  surface  of  the  skin;  the  slightest  pricking 
with  a  pin  causes  marked  pain.  For  several  minutes  during  the  ex- 
amination simple  contact  brought  forth  piercing  cries.  Considerable 
loss  of  flesh. 

(B)  Motor  Disorders. — The  most  frequent  are  -phenomena 
of  paralysis  and  of  paresis,  which  may  assume  the  most 
varied  types :  monoplegia,  hemiplegia,  facial  paralysis.  The 
latter,  generally  slight,  constitutes  a  very  frequent  and  often 
an  early  symptom. 

The  paralysis  is  either  flaccid  or  associated  with  contrac- 
tures. 


382  SYPHILITIC  DISORDERS 

A  certain  degree  of  motor  aphasia  is  often  observed. 

Paralysis  in  many  cases  follows  a  seizure  and  is  usually 
transitory. 

Convulsions  will  be  considered  in  connection  with  epilep- 
tiform seizures. 

Sometimes  choreiform  movements  are  observed  in 
general  paralysis  (Vallon  and  Marie),  also  tremors  analogous 
to  those  of  multiple  sclerosis  and  of  athetosis. 

(C)  Disorders  of  the  Reflexes. — The  best  known  and 
the  most  important  are  the  changes  in  the  patellar  reflex. 

There  is  nothing  constant  about  these,  as  they  vary 
not  only  in  different  patients  but  also  in  the  same  patient  at 
different  times. 

The  patellar  reflexes  may  be  normal,  exaggerated,  dimin- 
ished, or  abolished.  Sometimes  they  are  unequal  on  the  two 
sides:  one  may  be  exaggerated,  the  other  abolished. 

Complete  abolition  is  seen  in  the  tabetic  form,  exag- 
geration in  the  spastic  form. 

Other  tendon  reflexes  have  been  but  little  studied.  It 
has  been  noted  that  exaggeration  of  deep  reflexes  is  generally 
more  marked  in  the  upper  extremities. 

As  to  cutaneous  reflexes,  they  are  sometimes  exaggerated, 
more  often  abolished.  The  Babinski  sign  is  present  only  in 
cases  with  lesions  of  the  pyramidal  tracts,  especially  in  those 
with  combined  sclerosis. 

(D)  Disorders  of  Sensation. — These  have  been  well 
described  by  Marandon  de  Montyel,  from  whom  the  follow- 
ing facts  have  been  borrowed: 

(a)  Sensibility  to  pain  is  often  diminished,  less  frequently 
abolished,  rarely  exaggerated.  Some  patients  present  retard- 
ation of  the  perception  of  pain.  Disorders  of  pain  sensibility 
often  persist  during  remissions. 

(6)  Tactile  sensibility  is  usually  normal.  However,  there 
may  be  hypersesthesia,  hyposesthesia,  and  even  complete 
anaesthesia.     These  disorders  disappear  during  remissions. 

(c)  Special  senses:  disorders  of  hearing  (more  or  less 
marked  deafness,  tinnitus,  etc.)  are  not  infrequent,  but  by 


GENERAL  PARALYSIS  383 

reason  of  their  common  occurrence  in  other  mental  disorders 
and  in  normal  individuals  they  are  of  but  slight  importance. 

In  some  cases,  however,  the  deafness  is  of  central  origin 
and  seems  to  be  directly  due  to  the  meningo-encephalitis. 
Recently  I  had  under  my  observation  a  paretic  who  developed 
bilateral  deafness  following  an  apoplectiform  attack.  At 
first  his  deafness  was  remittent;  on  some  days  the  patient 
could  hear  fairly  well,  while  on  other  days  he  understood 
what  was  said  to  him  only  by  the  movements  of  the  lips  and, 
of  course,  but  very  imperfectly.  Now  his  deafness  is 
complete. 

Amblyopia  or  even  complete  amaurosis  is  sometimes 
encountered.  In  certain  cases  it  depends  upon  atrophy  of 
the  optic  nerve. 

The  senses  of  taste  and  smell  are  often  greatly  impaired. 

Disorders  of  the  generative  function  are  quite  frequent 
and  vary  with  the  stage  of  the  disease. 

The  onset  is  often  marked  by  genital  excitation,  which, 
associated  with  the  mental  deterioration,  may  lead  to 
indecent  or  criminal  acts:  exhibitionism,  rape,  etc.  Later 
this  excitation  is  replaced  by  absolute  impotence. 

(E)  Trophic  Disorders. — These  affect  all  the  tissues. 

Osseous  tissue:  abnormal  fragility  of  the  bones,  fractures 
caused  by  slight  traumatisms  or  even  occurring  spontane- 
ously. 

Connective  and  cartilaginous  tissues:  the  trophic  disorders 
are  here  chiefly  manifested  by  hcematoma  auris,^  which 
consists  in  an  extravasation  of  blood  into  the  tissues  of  the 
auricle. 

The  exact  seat  of  the  extravasation  in  hcematoma  auris  is 
still  a  disputed  question.  Some  are  of  the  opinion  that  it  is 
in  the  subcutaneous  tissues,  others  believe  that  it  is  between 
the  cartilage  and  the  perichondrium,  and  still  others  think 
that  it  is  within  the  cartilage  itself. 

Manifestations  of  trophic  disorders  are  usually  favored 

1  Gatian  de  Clerambault.  Contribution  a  I'etude  de  Vothematome. 
These  de  Paris,  1899. 


384  SYPHILITIC  DISORDERS 

by  traumatisms.  It  must  not  be  forgotten  that  the  great 
majority  of  hcematomata  auris  are  on  the  left  side  and  that 
when  one  receives  a  blow  it  is  usually  on  that  side.  It  is 
possible  to  reduce  considerably  the  number  of  hcematomata 
in  institutions  by  holding  the  attendants  directly  responsible 
for  their  occurrence. 

Skin. — Deformity  and  grooving  of  the  nails/  diverse 
eruptions,  herpes.  The  latter  lesion  indicates  involvement 
of  the  cord  in  the  pathological  process;  it  may  constitute 
one  of  the  first  symptoms  of  the  disease. 

The  most  frequent  and  most  grave  cutaneous  disturb- 
ances are  pressure-sores. 

Whether  bilateral  or  unilateral  they  develop  chiefly  at 
the  points  bearing  the  weight  of  the  body  while  the  patient 
is  in  bed;  hence  the  sacral,  gluteal,  and  trochanteric  bed- 
sores.    The  sacral  bed-sore  is  very  often  median. 

In  their  dimensions  they  vary  from  small  sores  of  the 
size  of  a  dime  to  those  exceeding  the  size  of  the  palm  of  the 
hand. 

Their  depth  also  varies  in  different  cases.  Some  remain 
superficial,  while  others  destroy  the  skin,  subcutaneous  tissue, 
and  muscles,  and  expose  the  bone. 

Their  course  is  often  progressive;  that  is  to  say,  they 
increase  in  extent  and  in  depth.  Sometimes  they  heal  under 
the  influence  of  appropriate  treatment. 

Muscles. — Localized  muscular  atrophy  is  rare.  It  affects 
different  groups  of  muscles  and  may  have  one  of  two  origins, 
resulting  either  from  degeneration  of  the  white  columns  of 
the  cord,  which,  in  its  turn,  is  caused  by  cerebral  lesions 
(Grelliere),^  or  from  primary  degeneration  of  the  cells  in 
the  anterior  horns  (Joffroy)  .^ 

^  Treves.  Su  alcani  alteretzioni  distrophiche  delle  unghi.  Rivist. 
di  clin.  medic,  1899,  No.  6. 

-  Grelliere.  Atrophie  musculaire  dans  la  paralysie  generale  des 
alienes.     Paris,  1875. 

^  Joffroy.  Contribution  a,  Vanatomie  pathologique  de  la  paralysie 
generale.     Congres  de  Medecine  mentale,  1892. 


GENERAL  PARALYSIS  385 

(F)  Visceral  Disorders. — These  are  dependent  either 
upon  the  disease  itself  or  upon  a  compUcation.  It  is  un- 
fortunately difficult  to  determine  in  any  given  case  what  the 
real  cause  is. 

(a)  Digestive  apparatus:  Its  functions  become  disturbed 
chiefly  in  the  terminal  stage  of  all  forms,  and  early  in  the 
depressed  and  excited  forms:  anorexia,  vomiting,  con- 
stipation, or  intractable  diarrhoea.  In  the  expansive  form 
one  often  notes  a  veritable  boulimia. 

(6)  Cardio-vascidar  apparatus:  E\ddences  of  atheroma, 
myocarditis,  rapid  and  feeble  pulse  in  the  terminal  cachexia. 
Aortic  insuflaciency  is  not  rare  and  is  probably  due  to  syphihs. 

(c)  Kidneys:  Shght  albuminuria  is  frequent.  This  with 
the  low  specific  gravity  of  the  urine  is  an  indication  of  a  cer- 
tain degree  of  renal  insufficiency. 

(d)  Liver:  Sometimes  hypertrophied,  more  rarely  atro- 
phied with  phenomena  of  cirrhosis.  The  ascites  that  usually 
accompanies  atrophic  cirrhosis  of  the  fiver  is  generally 
absent  in  the  cirrhosis  of  general  paralysis  (Klippel). 

(e)  Respiratory  apparatus:  Congestion,  broncho-pneu- 
monia, and  splenization  are  frequent  compfications  of  the 
last  stage.  Pulmonary  tuberculosis  is,  on  the  contrary, 
quite  rare  and  usually  runs  a  slow  course  (Bergonie,  Kfippel.) 

(G)  Seizures.^ — These  are  frequent,  occurring  at  all 
periods  of  the  disease  and  often  marking  the  onset.  They 
may  be  fatal.  According  to  Arnaud  death  from  a  seizure 
is  the  natural  mode  of  termination  of  general  paralysis. 
They  are  often  accompanied  by  elevation  of  temperature 
which  is  at  times  considerable.  In  some  cases  more  or  less 
marked  albuminuria  is  observed,  which  disappears  several 
hours  or  several  days  after  the  seizure. 

On  recovery  from  these  seizures,  which  is  most  usual, 
sjinptoms  of  apoplexy  (paralysis,  aphasia)  often  appear; 
they  are  almost  always  transitory,  there  being  no  gross 

^  Pierret.  Les  attaques  epileptiformes  et  apoplediformes  dans  la 
paralysie  generale.  Progres  medical,  1897. — ^Arnaud.  Arch,  de  neurol., 
1897.— Bonnat.     These  de  Paris,  1900. 


386  SYPHILITIC  DISORDERS 

lesions  of  the  corresponding  projection-centers.  The  seiz- 
ures are  generally  followed  by  an  aggravation  of  the  funda- 
mental psychic  and  physical  symptoms. 

The  seizures  are  of  two  kinds:  apoplectiform  and  epilep- 
tiform. 

The  former  are  characterized  by  more  or  less  complete 
loss  of  consciousness  associated  with  complete  flaccidity  of 
the  limbs. 

The  latter  consist  in  general  or  localized  convulsions. 
The  general  convulsions  sometimes  so  closely  simulate 
epilepsy  as  to  be  mistaken  for  it.  The  localized  convulsions 
assume  the  aspect  of  Jacksonian  epilepsy  (monocrural,  mono- 
brachial,  facial).  The  loss  of  consciousness  accompanying 
the  partial  convulsions  is  either  complete  or  reduced  to  a 
slight  degree  of  confusion,  as  in  the  case  of  convulsions 
due  to  focal  lesions,  such  as  cerebral  tumor  and  the  like. 

§  3.     Forms.     Evolution.     Diagnosis 

The  principal  forms  of  general  paralysis  are: 

(A)  Demented  form; 

(B)  Expansive  form; 

(C)  Excited  form; 

(D)  Depressed  form; 
tabetic; 


(E)  Spinal  forms     , 

^         ^  [  spastic. 

A.  Demented  Form. — This  form  constitutes  from  the 
psychic  standpoint  the  pure  type  of  general  paralysis,  free 
from  accessory  symptoms. 

The  onset  is  marked  chiefly  by  indifference  and  loss  of 
memory. 

When  the  disease  is  fully  established  the  symptoms  are 
those  of  profound  mental  deterioration,  which  we  have 
already  described,  associated  with  the  characteristic  physical 
disorders. 

This  form  is  frequent;  its  evolution  is  rapid  and  not 
interrupted  by  remissions. 


GENERAL  PARALYSIS  387 

B.  Expansive  Form. — Also  frequent. 
Special  features : 

Euphoria,  often  very  marked. 

Effusive  benevolence,  interrupted  by  transitory  outbreaks 
of  anger. 

Ideas  of  self-satisfaction  and  ideas  of  grandeur  (halluci- 
nations are  very  rare). 

.  Excitement,    loquaciousness. 

The  disease  begins  with  a  morbid  activity  and  slight 
excitement,  which,  associated  with  disorders  of  judgment, 
often  lead  the  patient  to  ruinous  deeds,  misdemeanors,  and 
even  crimes.  Unnecessary  purchases,  absurd  enterprises, 
violations  of  decency,  rape,  and  swindling  are  common. 
It  is  this  stage  that  constitutes  chiefly  the  medico-legal  period 
of  general  paralysis. 

The  evolution  of  this  form  is  slow.  The  duration  of  the 
illness  quite  frequently  exceeds  three  years.  Remissions 
are  frequent. 

C.  Excited  Form. — This  sometimes  begins  Avith  a  state 
of  excitement  and  confusion  resembling  mania  or  acute 
confusion. 

Its  special  features  are: 

Complete  loss  of  orientation  in  all  its  forms; 

Incoherent  delusions,  usually  associated  with  numerous 
hallucinations ; 

Violent  reactions  with  very  marked  motor  excitement; 

Profound  disturbances  of  general  nutrition. 

It  may  run  one  of  two  possible  courses:  the  excitement 
may  persist  and  death  supervene  within  a  few  months  or 
even  weeks  (galloping  general  paralysis) ;  or  the  excitement 
may  subside  and  the  disease  may  pass  into  one  of  the  other 
forms — demented,  expansive,  or  depressed. 

D.  Depressed  Form. — The  onset  is  marked  by  a  state 
of  depression,  so  that  the  trouble  may  be  mistaken  for 
involutional  melancholia  or  for  a  manic-depressive  attack. 

The  special  features  of  this  form  are : 
Psychic  inhibition; 


388  SYPHILITIC  DISORDERS 

Psychic  pain; 

Melancholy  delusions; 

Attempts  of  suicide  that  are  frequently  childish  and 
ineffective; 

Peripheral  vaso-constriction,  impairment  of  general 
nutrition ; 

Refusal  of  food. 

All  these  disorders,  however,  harmonize  less  perfectly 
with  each  other  than  in  the  constitutional  depressive  affec- 
tions. 

The  evolution  is  very  rapid.  Death  supervenes  early, 
and  is  due  to  cachexia  or  to  some  complication  (infection 
favored  by  the  impaired  nutrition  and  diminished  resistance 
of  the  tissues). 

E.  Spinal  Forms. — Tabetic  Form. — This  form  has  at 
the  beginning  the  aspect  of  ordinary  tabes.  The  signs  of 
general  paralysis  appear  much  later. 

Its  special  features  are: 

Lightning,  lancinating  pains;   girdle  sensation; 

Marked  ataxic  symptoms; 

Abolition  of  the  patellar  reflexes; 

Romberg  symptom; 

Argyll-Robertson  pupils. 

The  symptomatology  of  this  form  of  general  paralysis 
is,  however,  not  identical  with  that  of  pure  tabes.  The 
pains  are  less  severe,  the  urinary  troubles  less  frequent 
(Joffroy).  A  curious  fact  difficult  to  explain  is  that  as  the 
symptoms  of  general  paralysis  become  more  pronounced, 
those  of  tabes  (at  least  the  subjective  symptoms)  seem 
to  disappear. 

Spastic  Form.  {Form  with  Lateral  Sclerosis.) — This 
form  is  characterized  by  muscular  rigidity,  exaggeration  of 
reflexes  and  epileptoid  trembhng.  The  Babinski  sign  is 
almost  constant.  "  These  symptoms  are  sometimes  bilateral 
and  symmetrical,  at  other  times  unilateral,  and  still  at  other 
times,  at  the  onset  of  the  disease,  mobile  and  variable." 
(Dupre.) 


GENERAL  PARALYSIS  389 

The  different  forms  above  described  may  follow  each 
other,  or  they  may  be  associated  in  the  most  varied  ways. 

Course  and  Prognosis. — The  course  of  general  paralysis 
is  progressive,  and  has  been  schematically  divided  into  three 
stages,  not  including  the  prodromal  stage:  (1)  stage  of 
onset;  (2)  stage  of  complete  development;  (3)  stage  of 
cachexia. 

The  symptoms  at  the  stage  of  onset  are  very  variable. 
Generally  mental  symptoms  are  the  first  to  attract  attention 
and  even  to  suggest  the  diagnosis:  disorders  of  memory  and 
orientation;  the  patient  loses  his  way  in  the  streets  with 
which  he  is  most  familiar,  forgets  on  leaving  the  house  what 
he  started  out  for;  there  are  also  irritability,  outbursts  of 
anger,  attacks  of  depression  or  of  excitement  with  elation; 
more  or  less  active  delusions.  These  symptoms  are  not 
incompatible  with  a  certain  degree  of  mental  activity; 
hence  the  anomalies  of  conduct  leading  to  antisocial 
consequences  which  are  at  times  very  grave  and  which 
have  led  some  (Legrand  du  SauUe)  to  designate  this  stage 
of  the  disease  as  its  medico-legal  period.  The  patient  forgets 
the  most  common  conventionalities  and  makes  use  of 
obscene  language  in  public  and  in  the  presence  of  his  own 
children.  He  enters  upon  foolish,  ruinous  enterprises,  buys 
dozens  of  umbrellas,  cases  full  of  jewelry,  hundreds  of  copies 
of  the  same  book.  One  patient,  formerly  a  notary,  ordered 
in  one  day  twelve  tigers  from  Bengal,  "  tamed  "  in  Hamburg, 
five  thousand  pounds  of  tar  from  Paris,  and  five  hundred 
pounds  of  coffee  from  Port-au-Prince.  Often  a  paretic 
will  commit  thefts  and  frauds,  so  childish  in  character  as  to 
suggest  at  once  serious  mental  disturbance.  Finally  the  pa- 
tient's impulsiveness  may  lead  to  acts  of  violence,  murder, 
and,  when  combined  with  genital  excitation,  as  is  often  the 
case,  to  violations  of  decency  and  to  rape. 

In  this  stage  the  physical  signs  are  generally  not  fully 
developed;  yet  it  is  rare  for  them  to  be  entirely  wanting. 

The  second  stage,  that  of  complete  development,  is  the 
one  in  which  the  fundamental  symptoms  are  well  marked 


390  SYPHILITIC  DISORDERS 

and  the  delusions,  if  they  exist,  are  in  full  bloom;  yet  the 
patient  is  still  able  to  walk  around  and  to  eat  and  dress  with- 
out assistance.  There  is  in  this  stage  as  yet  no  loss  of 
sphincter  control  except,  perhaps,  for  occasional  brief  periods. 

The  stage  of  cachexia  is  characterized  by  complete  physical 
and  mental  dilapidation,  by  the  appearance  of  pressure-sores, 
and  by  permanent  loss  of  sphincter  control. 

The  prognosis  is  fatal.  Death  occurs  from  cachexia, 
from  some  complication,  or  as  the  result  of  an  apoplectiform 
or  epileptiform  seizure. 

The  average  duration  of  the  disease  is  two  or  three 
years.  There  is,  however,  no  fixed  rule  with  regard  to  this. 
In  exceptional  cases  the  disease  lasts  but  several  months 
or  weeks  (galloping  general  paralysis) ;  in  other  cases,  on  the 
contrary,  it  is  prolonged  for  ten  or  more  years. 

The  progress  of  the  disease  may  be  interrupted  by 
remissions.  Rarely,  except  at  the  beginning,  are  the  re- 
missions complete.  Almost  always  the  persistence  of  a  cer- 
tain degree  of  mental  deterioration,  or  at  least  of  a  neuras- 
thenic condition  and  of  physical  signs  exclude  any  idea  of 
true  recovery. 

Diagnosis. — The  fundamental  elements  of  diagnosis  are 
progressive  mental  deterioration  en  masse  and  the  character- 
istic physical  signs. 

General  paralysis  may,  especially  at  the  beginning,  when 
neither  the  mental  deterioration  nor  the  somatic  signs  are 
well  marked,  simulate  many  other  psychoses. 

Lumbar  puncture  is  here  of  great  service.  An  increase 
in  the  number  of  lymphocytes  in  the  cerebro-spinal  fluid 
is  almost  constant  in  general  paralysis,  especially  at  the 
onset. 

It  is  known  that  lymphocytosis  of  the  cerebro-spinal 
fluid  always  indicates  a  meningeal  inflammatory  lesion. 
Though  its  existence  does  not  point  positively  to  general 
paralysis,  yet  it  excludes  all  affections  in  which  there  are  no 
meningeal  lesions.  Thus  are  eliminated:  dementia  praecox, 
involutional  melancholia,  manic-depressive  psychoses,  epilep- 


GENERAL  PARALYSIS  391 

tic  psychoses,  alcoholic  psychoses,  and  exhaustion  psychoses. 
Further,  affections  with  a  basis  of  a  simple  process  of  atrophy, 
like  senile  dementia,  or  with  a  basis  of  a  central  lesion  without 
meningeal  involvement  (tumors  of  the  centrum  ovale,  hemor- 
rhages, cerebral  softening),  are  also  eliminated. 

The  cerebro-spinal  fluid  and  the  blood  may  also  be 
examined  for  the  Wassermann  reaction,  and  a  positive 
result  will  further  narrow  down  the  diagnosis  to  some  syphi- 
litic disorder. 

Lange's  colloidal  gold  test,  applied  to  the  cerebro-spinal 
fluid,  gives  a  very  characteristic  reaction  in  general  paralysis : 
complete  precipitation  in  the  first  two,  three,  or  four  tubes, 
partial  precipitation  in  the  next  two  or  three,  and  no  precipi- 
tation at  all  in  the  rest,  5555432100.     (See  Appendix  I.) 

Noguchi's  butyric  acid  test,  the  Ross-Jones  ammonium 
sulphate  test  and  Pandy's  phenol  test  usually  give  a  positive 
result  in  cases  of  general  paralysis  and  a  negative  result  in 
other  psychoses.  All  forms  of  meningitis,  however,  also 
give  a  positive  result. 

In  the  great  majority  of  cases  in  which  general  paralysis 
is  suspected  its  existence  can  be  either  established  or  excluded 
with  complete  certainty  with  the  aid  of  spinal  fluid  exami- 
nation. There  are,  however,  two  groups  of  cases  which  may 
present  extraordinary  difficulties  of  differentiation;  the 
first  consists  of  psychoses  essentially  of  a  non-syphilitic 
nature  occurring  in  combination  with  tabes:  here  one  must 
rely  mainly  on  the  mental  symptoms  for  the  differentiation, 
although  it  has  been  said  that  the  colloidal  gold  test  here 
gives  but  seldom  the  typical  reaction  described  above;  ^ 
the  second  group  consists  of  cases  of  cerebral  syphilis:  the 
differentiation  of  these  has  already  been  considered  in  the 
chapter  devoted  to  that  condition. 

1  D.  M.  Kaplan.  Serology  of  Nervous  and  Mental  Diseases.  Phila- 
delphia and  London,  1914. — Swalm  and  Mann.  The  Colloidal  Gold 
Test  on  Spinal  Fluid  in  Paresis  and  Other  Mental  Diseases.  N.  Y. 
Med.  Journ.,  Apr.  10,  1915. 


392  SYPHILITIC  DISORDERS 


PATHOLOGICAL   ANATOMY — ETIOLOGY TKEATMENT 

We  shall  describe  separately  the  lesions  of  the  encephalon, 
spinal  cord,  peripheral  nerves,  and  viscera. 

Pathological  Anatomy. — A.  Encephalon. — Dura  mater: 
often  congested,  presenting  occasionally  the  lesions  of  hemor- 
rhagic pachymeningitis. 

Pia-arachnoid  and  hrain. 

(a)  Macroscopic  lesions. 

(1)  General  atrophy  of  the  hrain,  most  marked  in  the 
frontal  and  parietal  lobes,  and  made  evident  by : 

a.  Flattening  of  the  convolutions; 

/5.  Thinning  of  the  cortex; 

7.  Diminution  of  the  weight,  most  marked  in  cases 
of  slow  evolution,  often  slight  or  absent  in  cases  of  general 
paralysis  of  very  rapid  course. 

(2)  Thickening  of  the  pia  mater  and  adhesions  between  it 
and  the  cerebral  substance:  stripping  off  the  pia  causes  a 
tearing  away  of  the  cerebral  substance,  especially  at  the 
frontal  and  parietal  lobes. 

(3)  Arteritis  of  the  large  and  medium-sized  cerebral  vessels: 
this  lesion  is  not  a  constant  one. 

(4)  Ependymal  granulations:  the  lining  of  the  ventricles 
is  thickly  studded  with  translucent  granulations,  which  are 
sometimes  very  minute,  like  a  fine  powder  sprinkled  over 
the  surface,  but  more  often  coarser,  resembHng  grains  of 
granulated  sugar.  Ependymal  granulations  are  fairly  con- 
stant in  general  paralysis;  outside  of  general  paralysis  they 
are  found  only  exceptionally. 

(6)  Microscopic  lesions.^ 

(1)    Nerve  cells. — Their  changes  are: 

a.  In  numbers  and  arrangement:    many  cells  disappear; 

1  Ballet.  Les  lesions  cerebrales  de  la  paralysie  generate.  Ann. 
med.  psych.,  1898. — Anglade.  Sur  les  alterations  des  cellules  nerveuses 
dans  la  paralysie  generate.  Ann.  med.  psych.,  July-Aug.,  1898. — 
Alzheimer.  Histologische  Studien  zur  Differentialdiagnose  der  progress. 
Paralyse.     Histol.  u.  histopathol.  Arbeiten.     Vol.  I,  1904. 


GENERAL  PARALYSIS  393 

the  different  layers  are  more  difficult  to  distinguish  than 
in  the  normal  state  and  appear  to  be  confounded; 

jS.  In  shape:  the  processes  disappear,  the  angles  become 
blunted,  the  cell-body  tends  to  reduce  itself  to  a  small, 
granular  and  pigmented  mass; 

7.  In  structure:  chromatolysis — that  is,  alteration  and 
destruction  of  Nissl's  corpuscles — which  causes  the  cell  to 
assume  a  hyaline  aspect  when  the  chromatic  substance  is 
destroyed,  or  to  present  a  uniform  coloration  if  stained 
by  the  aniline  pigments  when  this  substance,  reduced  to  a 
fine  powder,  is  disseminated  through  the  entire  cell. 

(2)  Nerve-fibers:  many  are  destroyed,  which  fact  can  be 
demonstrated  by  Pal's  or  Weigert's  hsematoxylin  stain. 
The  degeneration  affects  projection  fibers  as  well  as  associa- 
tion fibers,  but  more  particularly  the  superficial  tangential 
fibers  of  Exner-Tuczek. 

(3)  Pia  mater  and  blood  vessels: 

a.  The  pia  mater  is  thickened,  infiltrated  by  nuclei  repre- 
senting proliferating  fixed  connective-tissue  cells  or  migrating 
leucocytes. 

jS.  The  blood  vessels  are  much  more  numerous  than 
normally;  the  walls  are  thickened,  often  showing  hyaline  or 
fatty  degeneration;  the  perivascular  spaces  are  infiltrated 
with  cells.  The  appearance  of  these  lesions  is  similar  to 
those  of  diffuse  cerebral  syphilis.^ 

Among  the  cells  infiltrating  the  pia-arachnoid  and  the 
adventitial  coats  of  the  cortical  vessels  a  special  variety 
of  cells  occurs,  known  as  plasma  cells,  which  are  of  great 
importance  in  pathological  diagnosis,  since  they  are  constant 
in  general  paralysis  and  are  found,  according  to  Nissl,  in  no 
other  chronic  psychosis.  These  cells  are  somewhat  larger 
than  the  ordinary  round  cells,  contain  coarse,  deeply  stained 
granulations  in  their  nuclei,  and  a  relatively  large  amount 
of  finely  granular  protoplasm  which,  in  specimens  fixed  in 


^  Mahaim.     De   Vimportance   des   lesions   vasculaires,    etc.     Bullet, 
de  I'Acad.  roy.  de  Med.  de  Belgique,  July,  1901. 


394  SYPHILITIC  DISORDERS 

alcohol  and  stained  with  toluidin  blue,  takes  a  deep  purple 
stain. 

(4)  Neuroglia. — Proliferation  of  neuroglia-cells  is  very 
frequently  seen;  when  well  marked  it  is  especially  prominent 
in  the  vicinity  of  the  blood-vessels  (Mahaim).  Scantily 
distributed  here  and  there  may  be  seen  spider-cells  of 
abnormal  shape  and  of  gigantic  size. 

Among  the  most  constant  neuroglial  changes  must  be 
mentioned  the  ependymal  granulations  already  referred  t' 
above.  These  are  found  under  the  microscope  to  consist 
of  irregular  hillocks  upon  the  lining  of  the  ventricles,  formed 
by  great  proliferation  of  the  ependymal  glia  cells  which, 
instead  of  consisting  of  a  single  layer,  as  they  do  normally, 
are  in  these  hillocks  piled  up  in  half  a  dozen  or  more  irregular 
layers. 

(B)  Spinal  Cord. — (1)  Nerve  cells:  degenerative  and 
atrophic  lesions  identical  with  those  of  the  cerebral  cells. 

(2)  Nerve-fibers. — There  are  two  principal  types  of 
lesions — the  tabetic  type  and  the  type  of  combined  sclerosis. 

(a)  Tabetic  type. — The  degeneration  is  localized  in  the 
posterior  columns  and  is  similar  to  the  lesion  of  tabes:  this 
has  led  many  authors  to  look  upon  general  paralysis  and  tabes 
as  two  different  localizations  of  the  same  morbid  process.^ 

(6)  Combined  Sclerosis. — The  degeneration  involves  both 
the  posterior  and  the  lateral  columns.  Moreover,  the  process 
here  is  more  diffuse  and  affects  simultaneously  different 
systems  of  fibers  (tract  of  Gowers,  crossed  pyramidal  tract). 

(C)  Peripheral  Nerves. — The  lesions  of  the  peripheral 
nerves  consist  in  the  phenomena  of  neuritis  and  atrophy, 
analogous  to  those  encountered  in  tabes  and  in  alcoholism. 

(D)  Viscera. — Three  classes  of  lesions  may  be  distin- 
guished in  the  viscera: 

(1)  Lesions  occurring  merely  as  accidental  compli- 
cations: various  infections,  broncho-pneumonia,  tubercu- 
losis.    The  latter  is  rare  and  usually  runs  a  slow  course. 

^  Nageotte.     Tabes  et  Paralysie  generale.     These  de  Paris,  1893. 


GENERA.L  PARALYSIS  395 

(2)  Lesions  which  are  the  direct  consequences  of  the 
nervous  disorders.  These  have  been  studied  exhaustively 
by  Khppel,  who  has  termed  them  vasoparalytic  lesions. 
They  consist,  according  to  this  author,  "  in  a  high  degree 
of  congestion  and  capillary  engorgement,  capillary  hemor- 
rhages, and,  by  consequence,  atrophic  degeneration  of 
epithelial  tissues."  ^ 

(3)  Diffuse  vascular  lesions  identical  in  appearance 
with  those  of  the  cerebral  vessels. 

These  lesions  are  met  with  chiefly  in  the  kidneys,  liver 
and  heart,  and  are  often  associated  with  degenerative  lesions, 
such  as  fatty  or  cirrhotic  liver,  sclerotic  kidney,  or  degen- 
erated myocardium. 

Etiology. — In  1857  Esmarch  and  Jessen  were  led  by  the 
clinical  histories  of  their  cases  to  conclude  that  syphilis  was 
the  cause  of  general  paralysis;  but  their  view  gained  ground 
very  slowly.  In  France  Charcot  always  rejected  it,  and 
Dejerine  wTote  in  1886,  "  Syphilis  is  very  rarely  found  in 
the  histories  of  general  paralytics,  and  has  no  influence  on  the 
course  of  the  affection;  when  found  it  is  but  a  coincidence." 
Others  have  held,  with  Joffroy,  that  syphilis  was  a  strong 
factor  favoring  the  occurrence  of  general  paralysis  but  not  an 
essential  cause  of  it. 

Case  histories  alone  were,  naturally,  insuflacient  to 
establish  the  essential  part  played  by  syphilis  in  the  etiology 
of  general  paralysis,  a  history  of  syphilitic  infection  being 
by  no  means  always  obtainable;  but  the  case  came  to  be 
strengthened  on  anatomical  grounds  by  the  similarity 
between  the  lesions  of  general  paralysis  and  certain  syphilitic 
lesions. 

In  1897  Krafft-Ebing  presented  at  the  International 
Congress  of  Medicine  in  Moscow  further  important  evidence. 
A  physician,  whose  name  was  not  mentioned,  inoculated 

1  Klippel.  Lesions  des  poiimons,  du  cceur,  du  foie  et  des  reins  dans 
la  parahjsie  generale.  Arch,  de  med.  experim.  et  d'anat.  path.,  July, 
1892. — Angiolella.  Lesions  des  petits  vaisseaux  de  quelques  organes 
dans  la  parahjsie  generale.     II  manicomio,  1895,  Nos.  2  and  3. 


396  SYPHILITIC  DISORDERS 

with  syphilis  nine  general  paralytics  who  had  reached  the  last 
stage  of  the  disease  and  in  whose  history  syphilis  had  not 
been  found;  none  of  these  developed  a  chancre. 

The  advent  of  the  Wassermann  reaction  with  the  generally 
positive  finding  either  in  the  blood,  or  in  the  cerebro-spinal 
fluid,  or  in  both,  led  to  the  general  acceptance  of  the  view 
that  in  the  absence  of  syphilis  there  can  be  no  general  paral- 
ysis. But  the  nature  of  the  disease  still  seemed  obscure; 
especially  perplexing  was  its  resistance  to  anti-syphilitic 
treatment  in  contrast  with  other  syphilitic  lesions.  The 
disease  was  held  to  be  a  consequence  and  not  a  direct  mani- 
festation of  syphilis,  a  "  metasyphilitic "  (Moebius)  or 
"  parasyphilitic  "  (Fournier)  disorder,  possibly  in  the  nature 
of  an  autointoxication  (Kraepelin). 

Some,  however,  advanced  the  view,  based  on  various 
considerations,  that  general  paralysis  was  but  a  late  and 
peculiar  manifestation  of  still  active  syphilis.^  Others, 
notably  Lambert  and  Dunlap,^  have  insisted  that  a  sharp 
line  of  demarcation  cannot  be  drawn  between  general 
paralysis  and  cerebral  syphilis  and  have  brought  to  attention 
cases  which,  in  clinical  features  as  well  as  in  post  mortem 
findings,  represent  transition  or  combination  forms. 

The  nature  of  the  relationship  between  syphilis  and 
general  paralysis  was  finally  settled  by  Noguchi  and  Moore,^ 
who  found  the  treponema  pallidum  in  brain  sections  from 

1  Browning  and  McKenzie.  On  the  Wassermann  Reaction,  and 
Especially  its  Significance  in  Relation  to  General  Paralysis.  Journ, 
of  Mental  Science,  Vol.  LV,  1909. — Plaut  and  Fischer.  Die  Lues- 
Paralyse  Frage.  AUg.  Zeitschr.  f.  Psychiatrie,  Vol.  LXVI,  1909.— 
Rosanoff  and  Wiseman.  Syphilis  and  Insanity.  Amer.  Journ.  of 
Insanity,  Jan.  1910. 

2  C.  I.  Lambert.  A  Summary  Review  of  the  Syphilitic  and  Meta- 
syphilitic Cases  in  152  Consecutive  Autopsies.  N.  Y.  State  Hosp, 
Bulletin,  Aug.,  1912. — C.  B.  Dunlap.  Anatomical  Borderline  between 
the  so-called  Syphilitic  and  Metasyphilitic  Disorders.  Amer.  Journ.  of 
Insanity,  1913. 

^  Noguchi  and  Moore.  A  Demonstration  of  Treponema  Pallidum 
in  the  Brain  in  Cases  of  General  Paralysis.  Journ.  of  Exper.  Medicine, 
Vol.  XVII,  No.  2,  1913. 


GENERAL  PARALYSIS  397 

twelve  out  of  a  total  of  seventy  cases  of  general  paralysis 
examined  by  them.  This  finding  has  since  been  confirmed 
by  many  observers,  so  that  general  paralysis  is  now  regarded 
as  a  lesion  of  syphilis  affecting  the  brain  and  differing  from 
other  intracranial  syphilitic  lesions  by  the  fact  of  its  dis- 
tribution being  primarily  'parenchijmatous,  that  of  the  others 
being  meningeal,  vascular,  or  interstitial. 

The  clearer  knowledge  thus  gained  of  the  nature  of 
general  paralysis  affords  an  explanation  of  its  peculiar 
resistance  to  anti-syphilitic  treatment:  the  pathogenic 
organisms  are  embedded  in  situations  not  reached  by  the 
medication. 

There  is  still  much  in  the  etiology  of  general  paralysis 
that  is  not  well  understood.  The  most  important  question 
demanding  an  answer  is,  Why  do  some  syphilitics  eventually 
develop  general  paralysis  and  others  not?  Probably  not 
over  5%  of  syphilitics  develop  general  paralysis. 

In  this  connection  one  thinks,  perhaps,  first  of  all  of  a 
special  predisposition.  The  view  is  often  expressed  that  an 
inherited  neuropathic  constitution  renders  one  more  liable, 
on  contracting  syphilis,  eventually  to  develop  general 
paralysis,  this  view  being  based  on  the  fact  that  in  cases  of 
general  paralysis  one  finds  rather  frequently  a  family  history 
of  nervous  or  mental  diseases,  though  not  by  any  means  so 
frequently  as  in  the  constitutional  disorders.  It  is  doubtful, 
however,  if  this  view  is  really  supported  by  the  fact  on  which 
it  has  been  based,  as  the  latter  is  quite  susceptible  of  a  dif- 
ferent interpretation,  namely,  that  syphilis  itself  is  more 
likely  to  be  contracted  by  unrestrained,  dissipated,  and 
grossly  immoral  persons  than  by  others,  these  traits  bping, 
in  their  turn,  often  among  the  manifestations  of  neuropathic 
constitutions.  Thus,  while  a  special  susceptibility  to  the 
syphilitic  virus  may  possibly  have  something  to  do  with  the 
development  of  general  paralysis,  the  known  facts  do  not  seem 
to  necessitate  the  assumption  that  the  inherited  neuropathic 
constitutions  are  especially  related  to  this  susceptibility. 

Another  view  is  that  special  strains  of  the  syphilitic 


398 


SYPHILITIC  DISORDERS 


^ , .__^,_ . .^._.... yttfif  T  1 

Fig.  2. — Treponema  pallidum  in  the  Brain  of  General  Paralysis. 
(Noguchi  and  Moore.) 


GENERAL  PARALYSIS  399 

organism,  more  virulent  toward  nervous  tissues,  are  re- 
sponsible for  the  development  of  general  paralysis  and, 
perhaps,  of  other  lesions  of  the  nervous  S3^stem,  this  view- 
being  based  on  the  occasionally  observed  instances  of  con- 
jugal paresis  and  of  other  instances  of  general  paralysis 
occurring  in  two  or  more  persons  whose  syphilitic  infection 
can  be  traced  to  the  same  source.  Such  observations  are, 
however,  rare  and,  considering  the  great  prevalence  of 
syphilis,  may  be  explained  as  coincidences. 

That  the  distribution  of  an  organism  which  is  dissemi- 
nated by  the  blood  and  lymphatic  circulation  and  which  is 
itself  actively  motile  will  vary  in  different  cases  according  to 
mere  chance  would  seem  self  evident;  therefore  it  is  not 
surprising  that  some  cases  of  syphilis  should  have  liver 
lesions,  others  bone  lesions,  still  others  lesions  of  the  central 
nervous  system,  including  general  paralysis,  etc.,  as  their 
most  prominent  manifestations.  Yet  factors  other  than 
mere  chance  undoubtedly  play  a  part  in  some  cases.  TJead 
injury,  for  instance,  has  been  shown  by  numerous  carefully 
studied  cases  to  be  capable  of  starting  general  paralysis  in 
a  syphilitic  person,  acting,  possibly,  by  opening  a  way  for  the 
migration  of  treponemata  lodged  in  lymph  spaces,  interstitial 
tissues,  or  blood  vessel  walls  into  the  brain  parenchyma. 
Alcoholism  has  also  been  often  mentioned  as  an  exciting 
cause  of  general  paralysis,  but  it  is  difficult  to  determine 
the  exact  part  that  is  played  by  it  in  this  connection. 

It  is  a  remarkable  fact  that  in  cases  of  tabes  or  of  general 
paralysis  the  syphilis,  during  the  years  prior  to  the  involve- 
ment of  the  central  nervous  system,  runs  a  very  mild  course, 
often  hardly  furnishing  evidence  of  its  presence;  secondary 
and,  especially,  tertiary  manifestations  (iritis,  skin  erup- 
tions, gummata)  are  either  slight  or  absent ;  ^  and  at 
autopsies  in  cases  of  general  paralysis  one  seldom  finds  the 
lesions  ordinarily  observed  in  old  syphilitics,  such  as  endar- 
teritis,  arteriosclerosis,   valvular   heart   lesions,    aneurisms, 

1  E.  F.  Snydacker.  Absence  of  Iritis  and  Choroiditis  among  Syphi- 
litics who  have  become  Tabetic.     Journ.  Amer.  Med.  Assn.,  1910. 


400  SYPHILITIC  DISORDERS 

infarctions,  hepatic  cirrhosis,  etc.  It  would  seem  that  in  the 
cases  destined  to  develop  eventually  tabes  or  general  paral- 
ysis there  is  from  the  beginning  a  special  distribution  of  the 
sj^philitic  infection.  However  this  may  be,  the  mildness  of 
the  manifestations  usually  leads  to  neglect  of  treatment, 
and  that  may  certainly  be  said  to  increase  the  danger  of 
tabes  or  general  paralysis. 

Among  other  factors  in  the  etiology  of  general  paralysis 
the  most  important  are  sex,  age,  occupation,  and  environment. 

Syphilis  being  more  common  in  men  than  in  women, 
general  paralysis,  to<^,  occurs  more  commonly  in  men.  Thus, 
during  the  year  ending  June  30,  1918,  there  were  3530  male 
and  3267  female  first  admissions  to  the  New  York  state 
hospitals;  among  them  were  725  male  and  188  female  cases 
of  general  paralysis,  i.e.,  20.5%  and  5.8%  of  all  admissions, 
respectively.^ 

The  great  majority  of  cases  of  general  paralysis  occur 
between  the  ages  of  thirty  and  sixty.  Thus  of  a  total  of 
913  cases  of  general  paralysis  among  the  first  admissions  to 
the  New  York  state  hospitals  in  the  year  ending  June  30, 1918, 
but  62,  or  6.8%,  developed  T^efore  the  age  of  thirty,  and  but 
45,  or  4.9%,  at  sixty  or  over.^  Juvenile  and  even  infantile 
cases  are,  however,  sometimes  met  with,  occurring  generally 
on  a  basis  of  inherited  syphiHs. 

All  occupations  do  not  equally  predispose  to  syphilitic 
infection  and,  therefore,  to  general  paralysis;  unfortunately 
detailed  and  extensive  statistics  are  not  available.  It  is 
well  known  that  army  and  navy  officers,  traveling  salesmen, 
and  railroad  employees  furnish  a  comparatively  high  pro- 
portion of  cases  of  general  paralysis,  while  the  opposite  is 
true  of  Catholic  priests;  Krafft-Ebing,  for  instance,  saw 
among  2000  cases  of  general  paralysis  not  one  in  a  Catholic 
priest,  while  among  his  cases  of  insanity  in  army  officers  no 
less  than  90%  were  cases  of  general  paralysis.^    Among 

1  Thirtieth  Annual  Report  of  the  N.  Y.  State  Hospital  Commis- 
sion, Albany,  1919. 

2  Quoted  by  Kraepelin.     Psychiatrie.     8th  Edition.     Vol.  II. 


GENERAL  PARALYSIS  401 

women  professional  prostitutes,  naturally,  furnish  the  highest 
proportion  of  cases  of  general  paralysis. 

Syphilis  occurs  much  more  frequently  in  urban  than  in 
rural  environments;  accordingly,  urban  communities  fur- 
nish a  greater  proportion  of  cases  of  general  paralysis.  Thus, 
according  to  the  United  States  Census,  cities  of  100,000 
and  over  furnished  9.6  and  rural  communities  but  1.6  cases 
of  general  paralysis  per  100,000  of  the  general  population 
among  the  admissions  to  hospitals  for  the  insane  in  the  year 
1910.1 

Prevention  and  Treatment. — The  prevention  of  general 
paralysis  consists  mainly  in  measures  for  the  prevention  of 
syphihs,  which  have  already  been  discussed  in  Part  I,  Chapter 
XII. 

Early  and  thorough  treatment  of  every  case  of  syphilis 
has  also  already  been  mentioned  as  a  measure  for  the  pre- 
vention of  syphilitic  disorders  of  the  central  nervous  system. 

It  is  not  wise  to  postpone  treatment  until  a  positive 
Wassermann  reaction  is  obtained.  The  diagnosis  should  be 
made  as  early  as  possible  in  the  primary  period  by  demon- 
strating treponemata  in  the  initial  lesion  with  the  micro- 
scope by  the  dark  field  illumination  method. 

Another  point  is  to  perform  lumbar  puncture,  repeatedly 
if  necessary,  in  the  course  of  treatment  of  every  case  of 
syphilis,  whether  with  or  without  evidences  of  involvement 
of  the  central  nervous  system.  No  case  of  syphihs  should 
be  discharged  as  cured  untU  serological  findings  both  in  the 
blood  and  cerebro-spinal  fluid  have  become  permanently 
negative. 

In  some  cases,  in  spite  of  active  intravenous  treatment, 
positive  findings  persist  in  the  cerebro-spinal  fluid.  In  such 
cases  intraspinal  treatment  is  indicated. 

It  is  the  consensus  of  opinion  among  syphilologists  that 
patients,  in  whom  permanently  negative  serological  findings 
in  the  blood  and  cerebro-spinal  fluid  have  been  achieved  by 

^  Insane  and  Feeble-minded  in  Institutions.     1910. 


402  SYPHILITIC  DISORDERS 

treatment,  are  no  longer  in  danger  of  later  development 
of  tabes,  general  paralysis,  or  other  forms  of  neuro- 
syphilis. 

When  general  paralysis  has  developed  treatment  by 
anti-syphilitic  remedies,  at  least  as  ordinarily  adminis- 
tered in  cases  of  syphilis,  is  of  no  avail,  being  apt  even  to  do 
more  harm  than  good.  Recently  attempts  have  been  made 
to  bring  anti-syphilitic  remedies  more  directly  in  contact 
with  the  seat  of  the  lesion  by  administering  them  intra- 
spinally  or  intracranialh"  .^  Somewhat  encouraging^  results 
have  been  reported,^  though  it  is  still  very  doubtful  if  a 
permanent  arrest  of  the  process  has  been  brought  about  in 
any  case. 

For  the  rest,  the  treatment  is  merely  symptomatic. 
An  institutional  environment  seems  to  have  a  beneficial 
influence  in  many  cases,  a  calming  down  and  general 
improvement  being  often  observed  soon  after  ad- 
mission. 

Excitement,  insomnia,  suicidal  tendencies,  and  refusal 
of  food  are  to  be  treated  by  the  usual  methods. 

In  the  last  stage  great  care  must  be  taken  to  prevent 
the  development  of  bed  sores.  This  is  a  matter  of  proper 
nursing.  The  patient  must  be  kept  thoroughly  clean  and 
dry,  especially  when,  owing  to  loss  of  sphincter  control  or  to 
mental  deterioration,  he  soils  and  wets  himself  several  times 
a  day.     His  position  in  bed  must  be  changed  frequently  and 

1  Swift  and  Ellis.  The  Direct  Treatment  of  Syphilitic  Diseases 
of  the  Central  Nervous  System.  N.  Y.  Med.  Journ.,  July  13,  1912.— 
H.  S.  Ogilvie.  The  Intraspinal  Treatment  of  Syphilis  of  the  Central 
Nervous  System  by  Salvarsanized  Serum  of  Standard  Strength.  Journ. 
Amer.  Med.  Assn.,  Nov.  28,  1914.— D.  M.  Wardner.  A  Report  of 
Five  Cases  of  Intracranial  Injection  of  Auto-Sero-Salvarsan.  Amer. 
Journ.  of  Insanity,  Jan.,  1915. 

2  G.  S.  Amsden.  The  Intraspinal  Treatment  of  Paresis.  N.  Y. 
State  Hosp.  Bulletin,  Feb.  15,  1915.— H.  A.  Cotton.  The  Treatment 
of  Paresis  and  Tabes  Dorsalis  by  Salvarsanized  Serum.  Amer.  Journ. 
of  Insanity,  July  and  Oct.,  1915. — C.  A.  Neymann  and  N.  H.  Brush. 
The  Treatment  of  General  Paresis.     Arch,  of  Int.  Med.,  Aug.,  1918. 


GENERAL  PARALYSIS  403 

systematically  so  as  not  to  expose  either  one  side  or  the 
other  or  the  back  to  continuous  pressure  and  friction;  a 
pad  may  have  to  be  placed  between  the  knees  or  the  ankles 
in  cases  with  a  tendency  to  contractures.  The  bed  must  be 
made  carefully,  avoiding  unevenness,  roughness,  or  wrinkles 
in  the  bed  clothes.  The  skin  over  the  parts  that  are  exposed 
to  pressure  may  be  somewhat  protected  by  sponging  with 
alcohol,  drying,  and  dusting  with  talcum  powder.  An  air- 
or  water-bed  may  be  used,  but  will  be  found  hardly  neces- 
sary where  the  above-mentioned  precautions  are  carefully 
observed.  When  bed  sores  develop  they  are  to  be  treated 
by  frequent  and  careful  cleansing  and  protected  by  a  simple 
dressing;  the  application  of  a  saturated  solution  of  picric 
acid  seems  often  to  promote  healing. 

Broncho-pneumonia  is  a  common  complication  of  general 
paralysis  and  is  in  the  majority  of  cases  the  immediate  cause 
of  death.  No  doubt  the  general  debilitating  effect  of  the 
disease  renders  the  patient  more  liable  to  develop  this  com- 
plication, and  the  chances  are  further  increased  in  the  last 
stage  when  difficulties  of  deglutition  develop  and  food  is 
apt  to  find  its  way  into  the  respiratory  passages.  Yet  here 
too,  careful  nursing  can  accomplish  a  good  deal,  and  it  is  safe 
to  say  that  the  frequency  of  broncho-pneumonia  can  be 
considerably  reduced.  Demented  patients  will  not  com- 
plain of  feeling  cold,  and  it  is  the  nurse's  duty  to  have  the 
patient  at  all  times  comfortably  clad,  well  covered  if  in  bed, 
and  protected  from  draughts;  special  care  must  be  ob- 
served when  the  patient  has  occasion  to  sit  up  in  his  bed,  or 
leave  his  bed,  and  in  bathing.  Patients  having  to  take  their 
meals  in  bed  should  be  placed  in  an  easy,  natural  position, 
propped  up  with  pillows,  and  not  so  as  to  have  to  reach  over 
the  side  of  the  bed  to  get  the  food  or  to  have  to  eat  while 
partly  reclining;  when  deglutition  becomes  difficult  or 
uncertain  they  must  not  be  allowed  to  feed  themselves,  but 
must  be  fed  by  a  nurse  or  attendant  slowly  with  finely 
divided  food. 

There  is  nothing  ordinarily  to  be  done  for  convulsions 


404  SYPHILITIC  DISORDERS 

beyond  protecting  the  patient  against  injury.  Continued 
convulsions  are  sometimes  successfully  combated  by  a  high 
enema  followed  by  the  administration  of  30  grains  of  potas- 
sium bromide  and  20  grains  of  chloral  hydrate  per  rectum, 
repeating  the  dose  in  an  hour  if  necessary. 


CHAPTER  XV 

SYPHILITIC  DISORDERS  {Concluded) 
CEREBRAL  ARTERIOSCLEROSIS  ^ 

Cerebral  arteriosclerosis  is  not  always  of  syphilitic 
origin,  though  probably  much  more  frequently  so  than  would 
be  indicated  by  clinical  statistics. 

Disease  of  the  arteries  of  the  brain  is  often  found  at 
autopsies  in  cases  which  have  shown  during  Ufe  no  mental 
or  nervous  disturbances.  The  occurrence  of  such  dis- 
turbances is  probably  determined  by  a  certain  extent  or 
degree  of  arterial  disease.  Arteriosclerotic  brain  disease 
is  but  a  part  of  general  arteriosclerosis,  though  not  infre- 
quently the  process  is  found  to  be  much  more  marked  in  the 
brain  than  elsewhere. 

The  symptoms  vary  widely  in  different  cases,  depending 
chiefly  upon  the  vessel  or  system  of  vessels  affected. 

Fig.  3  is  a  diagram  of  the  arterial  supply  of  the  brain 
showing  the  circle  of  Willis,  its  branches  and  their  dis- 
tribution. 

The  terminal  arterioles  form  two  distinct  systems:  a 
system  of  short  vessels  supplying  the  cortex,  and  a  system 
of  long  vessels  which  penetrate  deeper  and  supply  the 
marrow;    the  ganglionic  vessels  at  the  base  constitute  a 

^Binswanger.  Berlin,  klin.  Wochenschr.,  1894. — Alzheimer.  Allg. 
Zeitschr.  f.  Psychiatrie,  1902. — Gowers.  Manual  of  Diseases  of  the 
Nervous  System. — Lambert.  N.  Y.  State  Hosp.  Bulletin,  Vol.  I; 
also  in  20th  Ann.  Report  N.  Y.  State  Commission  in  Lunacy,  pp.  91 
et  seq. 

405 


406 


SYPHILITIC  DISORDERS 


marginal  convolution. 
Superior  and  middle  frontal  convolutions. 
Upper  part  of  ascending  frontal  convolution. 


Gorpus  callosum. 

Gyrus  fomicatug. 

Inner  surface  of  first  frontal  convolution. 

Upper  part  of  ascending  frontal  convolution. 


Lobus  quadratus  and 

adjacent  outer  surface  of  hemiBphere. 


Third  frontal  convolution  and  outer  part 
of  orbital  surface  of  frontal  lobe.   


Ascending  frontal 
convolution. 


Ascending  parietal  convoitttion 
and  lower  part  of  superior 
parietal  convolution. 


Supramarginal  gyms. 

First  temporal  convolution.. 

Part  of  second  temporal  convolution. 

Angular  gyrus. 


External  occipital  convolution. 
Third  temporal  convolution. 


Inner  and  outer  smfaces 
of  the  occipital  lobe 


Fig.  3. — Arterial  Supply  of  the  Brain. 


CEREBRAi   ARTERIOSCLEROSIS 


407 


part  of  the  medullary  system.     The  manner  of  distribution 
of  the  terminal  arterioles  is  shown  in  Fig.  4. 

Arteriosclerotic  disease  may  affect  chiefly  the  large 
vessels  given  off  from  the  circle  of  WilUs  or  their  principal 
branches;  or  it  may  affect  chiefly  the  terminal  arterioles, 
either  the  cortical  or  the  medullary  system,   though  the 


Fig.  4. — 1.  Long  or  Medullary  Arteries.       2.  Short  or  Cortical  Arteries. 
(After  Charcot,  from  Gray's  Anatomy.) 


process   is   hardly  ever  sharply  Umited  to  any  one  system 
of  vessels. 

The  manner  in  which  the  nervous  tissues  are  affected 
ie  variable.  Narrowing  of  the  lumen  of  a  vessel  resulting 
from  obliterative  endarteritis  brings  about  atrophy  of  the 
nervous  elements,  due  to  reduction  of  the  blood  supply, 
there  being  at  the  same  time  hypertrophy  of  the  neuroglia 
tissue  ("perivascular  gliosis"  of  Alzheimer);   thickening  of 


408  SYPHILITIC  DISORDERS 

the  walls  of  the  smallest  arterioles  and  of  the  capillaries 
("  arterio-capillary  fibrosis ")  results  in  atrophy  through 
interference  with  osmotic  processes;  roughening  of  the  in- 
timal  lining  of  the  vessels  results  in  the  formation  of  thrombi 
or  emboli  with  consequent  infarction  and  softening;  the 
brittle  and  weakened  condition  of  the  vessel  walls  and 
aneurismal  dilatations  combined  with  general  rise  of  blood 
pressure  result  in  rupture  and  hemorrhage  with  compression 
and  destruction  of  nerve  tissue  to  an  extent  depending  upon 
the  amount  of  extravasated  blood. 

The  symptoms  of  arteriosclerotic  brain  disease  may 
perhaps  be  most  conveniently  classified  as  follows:  (1) 
systemic  symptoms;  (2)  symptoms  common  to  all  forms  of 
arteriosclerotic  brain  disease;  (3)  symptoms  of  occlusion  of 
large  vessels  or  their  branches;  (4)  symptoms  of  affection 
of  the  medullary  system  of  terminal  arterioles;  (5)  symptoms 
of  affection  of  the  cortical  system  of  terminal  arterioles. 

(1)  Systemic  Symptoms.  These  will  not  be  dwelt  upon 
in  detail  here,  as  they  are  more  properly  a  subject  of  text- 
books of  general  medicine.  As  being  among  the  most 
important  may  be  mentioned :  rigid  and  tortuous  peripheral 
arteries,  increased  blood  pressure,  pulse  high  in  tension  but 
small  in  volume,  increased  area  of  cardiac  dullness,  accentu- 
ation of  the  aortic  sound,  often  evidences  of  chronic  inter- 
stitial nephritis. 

(2)  Symptoms  Common  to  all  Forms  of  Arteriosclerotic 
Brain  Disease,  (a)  Physical  symptoms:  headache,  in- 
somnia, muscular  weakness,  imperfect  muscular  control, 
attacks  of  faintness  or  dizziness,  epileptiform  or  apoplecti- 
form seizures.  (6)  Mental  symptoms:  diminished  capacity 
for  work,  undue  fatigability,  emotional  instability,  states  of 
depression  or  anxiety,  drowsiness;  later  forgetfulness, 
disorientation,  and  general  mental  deterioration ;  a  character- 
istic feature  is  the  persistence  of  insight  for  a  long  time. 

(3)  Symptoms  of  Occlusion  of  Large  Vessels  or  Their 
Branches.  The  symptoms  usually  come  on  suddenly  in  the 
form  of  a  stroke,  often,  but  by  no  means  always,  accom- 


CEREBRAL  ARTERIOSCLEROSIS  409 

panied  by  loss  of  consciousness  lasting  from  a  few  minutes 
to  several  hours  or  even  longer;  this  may  be  followed  by  a 
dazed,  confused,  or  delirious  period  from  which  the  patient 
recovers  with  permanent  symptoms  the  character  of  which 
depends  upon  the  location  and  extent  of  the  lesion. 

(a)  Occlusion  of  the  anterior  cerebral  artery  is  uncormnon ; 
the  symptoms  depend  upon  the  point  of  occlusion  and  upon 
whether  the  main  vessel  or  one  of  its  branches  is  occluded; 
there  may  be  no  special  symptoms,  or  there  may  be  loss  of  the 
sense  of  smell  on  one  side  or  crural  monoplegia. 

(6)  Occlusion  of  the  middle  cerebral  artery  or  of  its 
branches  is  very  conunon;  the  characteristic  symptoms 
for  the  four  branches  respectively  are:  (a)  motor  aphasia; 
(iS)  facial  or  brachial  paralysis,  or  both;  (7)  astereognosis; 
(8)  partial  bilateral  deafness,  sensory  aphasia,  possibly 
lower  quadrant  hemianopsia.  Lesions  of  the  right  hemi- 
sphere produce  no  aphasia  in  right-handed  persons. 

(c)  Occlusion  of  the  posterior  cerebral  artery  has  for 
its  special  symptom  hemianopsia;  this  symptom,  however, 
occurs  only  when  either  the  main  vessel  or  its  occipital 
branch  is  affected. 

(d)  The  cerebellar  arteries  communicate  with  each  other 
by  fairly  free  anastomosis;  for  that  reason  occlusion  of  one 
of  them  may  cause  but  slight  darhage  and  give  rise  to  no 
permanent  symptoms;  when  the  area  of  softening  is  exten- 
sive there  are  apt  to  be  vomiting,  vertigo,  and  muscular  in- 
coordination. In  some  cases  the  lesion  involves  parts  of  the 
pons  and  medulla,  causing  crossed  hemianeesthesia,  loss  of 
the  sense  of  taste,  dysphagia,  and  aphonia,  and  rapidly 
leading  to  a  fatal  termination. 

Occlusion  of  these  vessels  does  not  in  itself  as  a  rule 
cause  marked  general  mental  deterioration  aside  from  that 
which  is  the  characteristic  accompaniment  of  states  of 
aphasia. 

(4)  Disease  of  the  Medullary  System  of  Terminal  Arterioles 
("  chronic  subcortical  encephahtis  "  of  Binswanger)  presents 
a  characteristic  picture  at  autopsy:  the  brain  shows  more  or 


410  SYPHIIITIC  DISORDERS 

less  pronounced  atrophy  which  is  general  but  which  is  apt 
to  be  more  marked  in  irregular  foci;  the  surface  of  the  brain 
is  smooth,  the  cortex,  though  possibly  somewhat  thinned,  is 
otherwise  normal  in  gross  appearance;  the  white  substance 
and  often  the  basal  ganglia  present  on  section  slit-like 
defects  where  the  nerve  substance  has  disappeared  either 
by  gradual  atrophy  or  through  sudden  infarction;  these 
defects  may  be  so  numerous  that  the  brain  substance,  riddled 
with  them,  presents  a  spongy  appearance  which  has  been 
called  etat  crible;  in  other  cases  there  may  be  but  one  or 
two  of  them  in  each  hemisphere.  The  distribution  of  the 
affection  is  variable;  usually  it  is  bilateral;  in  some  cases, 
however,  it  may  involve  largely  one  hemisphere,  the  other 
being  almost  entirely  spared;  in  other  cases  the  ganglionic 
vessels  are  the  principal  seat  of  the  affection. 

The  more  striking  clinical  features  of  this  type  of  cerebral 
arteriosclerosis  are  recurrent  epileptiform  or  apoplectiform 
seizures  and  paralyses,  anaesthesias,  and  mental  deteriora- 
tion the  course  of  which  is  irregularly  progressive,  increas- 
ing with  each  seizure  and  remaining  stationary  or  even 
receding  somewhat  in  the  intervals;  toward  the  last  the 
patients  become  helpless  owing  to  paralyses,  contractures, 
and  profound  dementia. 

In  cases  in  which  the  affection  is  largely  confined  to  the 
ganglionic  vessels  the  dementia  is  but  slight.  In  such  cases 
there  is  a  special  tendency  toward  the  formation  of  small 
aneurisms  which  frequently  burst,  and  the  resulting  hemor- 
rhage into  the  basal  nuclei,  the  internal  capsule,  and  the 
lateral  ventricle  gives  rise  to  the  familiar  clinical  picture  of 
cerebral  apoplexy  followed  by  hemiplegia,  dysarthria,  etc. 

(5)  Disease  of  the  Cortical  System  of  Terminal  Arterioles 
also  presents  a  characteristic  anatomical  picture.  The 
surface  of  the  cortex  instead  of  being  smooth  is  irregularly 
pitted  with  small  depressions  which  mark  the  sites  of  atrophy 
and  contraction  in  the  regions  supplied  by  the  cortical  arteri- 
oles the  lumina  of  which  have  become  narrowed  or  com- 
pletely obstructed.     The  lesion  is  as  a  rule  unequally  dis- 


CEREBRAL  ARTERIOSCLEROSIS  411 

tributed  but  rather  extensive,  so  that  there  is  marked 
general  brain  atrophy.  Microscopically  one  finds  various 
stages  of  chronic  nerve  cell  change :  pigmentary  degeneration 
shrinkage,  atrophy;  the  nervous  elements  in  the  affected 
areas  ultimately  disappear  and  are  replaced  by  glia  tissue. 

Clinically  the  special  feature  here  consists  in  various 
irritative  phenomena  followed  later  by  loss  of  function: 
tremors,  athetoid  or  choreiform  movements,  various  seizures, 
parsesthesias,  and  later  paralyses  and  anaesthesias.  The 
mental  symptoms  are  apt  to  be  prominent  from  the  begin- 
ning: hallucinations,  agitation,  violent  excitement,  confusion, 
inaccessibility. 

Diagnosis. —  General  paralysis  may  be  closely  simu- 
lated but  can  always  be  excluded  with  the  aid  of  lumbar 
puncture  which  in  cerebral  arteriosclerosis  regularly  gives 
negative  results. 

Acute  syphilitic  endarteritis  affecting  the  brain  arteries 
may  be  clinically  indistinguishable  from  cerebral  arterio- 
sclerosis. The  differentiation  may  be  made  with  the  aid 
of  the  Wassermann  reaction.  Cases  of  arteriosclerotic 
brain  disease,  even  when  due  to  old  syphilitic  infection, 
usually  give  a  negative  reaction,  for  in  such  cases  as  a  rule  the 
syphilitic  process  is  no  longer  active,  the  lesions  be.ing  post- 
syphilitic. 

The  differentiation  from  senile  dementia  may  be  difficult 
especially  when  the  latter  is  complicated  by  more  or  less 
marked  arteriosclerosis,  as  is  so  often  the  case.  It  must  be 
borne  in  mind  that  senile  dementia  has  for  its  basis  a  process 
of  atrophy  which  is  wholly  independent  of  vascular  disease. 
Focal  symptoms,  recurrent  seizures,  persisting  mental 
insight,  also  stationary  condition  and  duration  over  five 
years,  all  point  to  cerebral  arteriosclerosis.  Senile  dementia 
is  but  exceptional  before  the  age  of  sixty  years,  while  cerebral 
arteriosclerosis  often  begins  at  fifty  or  even  earlier. 

The  course  of  cerebral  arteriosclerosis  in  most  cases 
extends  over  a  number  of  years,  even  ten  or  twenty  years. 
It  is  irregularly  progressive,  as  already  described.     In  any 


412  SYPHILITIC  DISORDERS 

case  sudden  death  may  occur  from  embolism,  apoplexy,  or 
from  exhaustion  following  convulsions.  Kraepelin  speaks 
of  a  grave  progressive  form  which  is  characterized  by  rapid 
development  of  extreme  dementia  and  an  early  fatal  ter- 
mination. 

The  prognosis  of  all  forms  of  arteriosclerotic  brain  disease 
is  unfavorable  for  recovery  from  established  defect  symp- 
toms; sudden  or  gradual  progress  of  the  disease  is  to  be 
expected  to  occur  sooner  or  later,  though  the  condition  may 
remain  approximately  stationary  for  months  or  even  years, 
expecially  under  favorable  conditions. 

The  treatment  is  purely  symptomatic.  Rest,  freedom 
from  worry  or  excitement,  moderation  in  eating  and  drink- 
ing, abstinence  from  alcohol,  proper  regulation  of  the  bowels 
may  stave  off  progress  of  the  disease  or  the  occurrence  of 
seizures. 


CHAPTER  XVI 
TRAUMATIC  DISORDERS 

Traumatisms  may  play  a  part  in  the  etiology  of  psycho- 
ses essentially  of  a  constitutional  nature,  and  they  have  been 
known  to  cause  the  development  of  general  paralysis  in 
syphilitic  persons;  it  is  believed  also  that  they  can  precipi- 
tate an  attack  of  delirium  tremens  in  an  alcoholic  person. 
Such  cases  are  not  included  here  under  the  designation  of 
traumatic  psychoses,  but  only  those  in  which  the  traumatism 
constitutes  the  essential,  if  not  the  sole,  cause  of  the  mental 
disorder. 

As  already  stated  in  the  chapter  on  Etiology,  trau- 
matic psychoses  are  comparatively  rare  in  psychiatric  prac- 
tice: but  0.44%  of  all  male  first  admissions  and  0.06%  of 
all  female  first  admissions  to  the  New  York  state  hospitals 
during  the  year  ending  June  30,  1917,  were  cases  of  traumatic 
psychoses. 

The  immediate  results  of  head  injuries  come  more 
frequently  under  the  observation  of  surgeons  than  psychia- 
trists. 

The  nature  of  the  injury  in  cases  of  traumatic  psychoses 
is  variable:  fractures  with  depression  of  fragments  and 
destruction  of  brain  tissue  by  direct  violence;  compression 
or  brain  tissue  destruction  resulting  not  directly  from  the 
injury  but  indirectly  from  an  intra-cranial  hemorrhage 
following  it;  severe  concussion  in  cases  with  linear  fracture 
without  encroachments  on  the  cranial  cavity  or  even  in  cases 
without  fracture;  bullet  wounds,  etc.  Complicating  in- 
fections naturally  bring  with  them  febrile  or  infectious 
deliria  the  manifestations  of  which  it  is  difficult,  if  not  impos- 

413 


414  TRAUMATIC  DISORDERS 

sible,  to  separate  from  the  symptoms  directly  attributable 
to  the  injury. 

Many  cases  of  head  injury  undoubtedly  occur  without 
any  considerable  injury  to  the  brain,  and  this  in  part  accounts 
for  the  rarity  of  marked  and  lasting  mental  complications; 
yet  it  is  also  true  that  fairly  extensive  injury  to  the  brain 
may  occur  without  giving  rise  to  such  complications.  It 
would  seem  that  mental  symptoms  are  determined  by  the 
diffuse  effects  of  concussion,  compression,  or  bruising, 
rather  than  by  any  special  localization  of  circumscribed 
lesions. 

The  first  effect  of  a  head  injury  is  a  dazed,  stunned,  or 
completely  unconscious  condition  which  comes  on  either 
immediately  or,  where  due  to  an  intra-cranial  hemorrhage, 
after  an  interval  following  the  injury.  This  lasts  from  a 
few  minutes  to  several  hours,  after  which  consciousness  may 
be  fully  regained  or  the  patient  may  remain  somnolent  for 
several  days  and  then  recover.  Cases  of  very  severe  injury 
often  terminate  in  death  without  return  of  consciousness. 

Traumatic  Delirium. — Delirium  following  head  injuries 
is  observed  either  immediately  after  the  initial  coma  or 
stupor  or  after  a  brief  interval  of  comparative  lucidity.  It 
is  characterized  by  restlessness,  which  may  be  slight  and 
readily  controllable  or  may  become  aggressively  violent, 
disorientation,  disconnectedness  of  utterances,  more  or  less 
relevant  but  peculiarly  absurd  and  irrational  responses,  and 
tendency  to  fabrication;  psycho-sensory  disturbances  may 
occur  but  do  not  seem  to  be  as  prominent  as  in  other  deliria. 

The  possible  terminations  are  death,  complete  recovery, 
and  recovery  with  mental  or  physical  residuals.  The  dura- 
tion of  cases  which  survive  usually  extends  over  several 
weeks,  and  in  some  cases  convalescence  lasts  for  weeks  or 
even  months  after  the  acute  period  of  the  illness.  In  the 
treatment  the  advisability  of  early  surgical  interference 
should  always  be  considered;  not  only  may  an  immediate 
amelioration  be  often  produced  by  raising  depressed  parts 
of  bone,  removing  intra-cranial  blood  extravasations,  etc., 


TRAUMATIC  DELIRIUM  415 

but  also  some  of  the  possible  sequelae  may  be  prevented. 
The  danger  of  craniotomy  is  now  so  slight  that  its  per- 
formance in  doubtful  cases  would  seem  justifiable  even  merely 
for  exploration. 

The  following  case  is  quite  typical: 

Adrien  D.,  mason,  aged  thirty-five,  without  abnormal  family  or 
personal  antecedents,  fell  from  a  scaffolding  about  five  meters  high 
upon  unpaved  but  dry  and  hard  ground.  He  was  picked  up  uncon- 
scious and  taken  to  his  home. 

Externally  was  found  only  a  small  contused  wound  at  the  top  of  the 
head,  without  lesion  of  the  bone,  which  healed  in  a  few  days. 

After  being  in  coma  eighteen  hours  the  patient  gradually  regained 
consciousness,  but  for  eight  days  remained  in  a  state  of  marked  confu- 
sion. He  is  stupid,  dull,  completely  disoriented  as  to  place  and  time, 
and  dreams  a  good  deal,  especially  at  night.  He  reacts  to  physical 
stimulation  (pricking,  pinching),  but  does  so  slowly  and  feebly.  He 
does  not  respond  to  questions  unless  they  are  very  simple. — He  has 
become  oriented  as  to  place  but  is  still  completely  disoriented  as  to 
time.  His  attention  is  difficult  to  gain  and  impossible  to  hold.  Recol- 
lection of  occurrences  preceding  the  accident  is  labored  and  inaccurate. 
He  has  complete  amnesia  for  the  accident  and  what  followed.  Actual 
impressions  are  fixed  in  his  mind  for  but  a  very  short  time:  at  the  end  of 
five  minutes  he  forgot  that  he  had  been  visited  by  the  physician.  He 
often  brings  his  hand  up  to  his  head  without  saying  anything,  and  when 
asked  if  it  hurts  him  says,  "  Yes,  a  little."  In  the  day  time  some 
illusions  are  noted,  the  patient  mistaking  persons  for  one  another. 
Sleep  is  scarce,  and  the  greater  part  of  the  night  is  passed  in  a  dream 
state,  chiefly  occupational:  he  thinks  it  is  time  to  go  to  his  work,  asks 
for  his  clothes,  gets  up  and  looks  for  his  tools,  converses  with  imaginary 
persons,  complains  that  the  cords  have  not  been  properly  placed,  that 
the  mortar  is  too  thick,  etc. 

After  the  first  week  attention  and  memory  improved  a  little.  The 
patient  retains  some  few  impressions;  yet  the  amnesia  of  fixation,  though 
no  longer  complete,  as  in  the  preceding  period,  is  still  very  marked.  The 
disorientation  of  time  persists.  A  most  active  and  mobile  tendency  to 
confabulation  has  appeared.  One  month  after  the  accident,  when  the 
patient  had  not  yet  left  his  bed,  he  told  of  having  been  eight  days  before 
at  the  fair  in  X.,  where  his  brother-in-law,  a  cattle  dealer,  had  gone  to 
sell  some  oxen.  In  response  to  leading  questions  he  gives  minute  details, 
which  vary  from  one  moment  to  the  next  and  become  contradictory. 
When  the  contradictions  are  pointed  out  to  him  he  admits  readily  that  he 
may  have  been  mistaken  as  his  memory  had  failed  him.     The  realiza- 


416  TRAUMATIC  DISORDERS 

tion  of  his  abnormal  state  is,  however,  but  transitory  and  weak.  When 
told  that  he  is  sick  and  must  take  care  of  himself  he  shows  an  irritability 
not  previously  noted,  falls  into  violent  anger,  refuses  medicine  which  is 
offered  him,  saying  he  has  had  enough  and  wants  to  go. 

He  has  a  vague  idea  that  he  has  been  in  an  accident,  but,  although  it 
has  been  spoken  of  many  times  in  his  presence,  cannot  tell  the  exact 
circumstances  of  it.  Until  the  sixth  week  he  knew  only  that  he  had 
fallen,  but  from  where,  what  height,  how,  he  did  not  know:  perhaps 
from  a  roof,  or  a  ladder,  or  a  scaffold — such  things,  he  said,  happened 
often  in  his  trade.  Sometimes,  by  way  of  confabulation,  he  becomes 
more  specific.  Thus  about  five  weeks  after  the  accident  he  told  how 
he  had  fallen  from  a  carriage  while  he  and  his  master  were  on  their 
way  to  see  what  work  there  was  to  be  done.  Another  day  he  told  that 
a  heavy  brick  had  fallen  on  his  head.  (In  fact  he  had  had  a  brick  fall 
on  his  head  about  two  years  previously,  but  from  a  very  low  height 
and  without  causing  any  appreciable  harm.) 

He  inquires  from  time  to  time  if  his  insurance  has  been  paid,  but 
does  not  occupy  himself  effectually  with  the  defence  of  his  rights  and 
does  not  seem  to  be  interested  in  the  progress  of  the  negotiations  con- 
cerning this  matter. 

Physically  there  is  to  be  noted,  aside  from  the  headache  mentioned 
above,  only  a  general  muscular  weakness  and  some  vertigo.  No  signs 
of  any  localized  cerebral  lesion.     No  convulsive  manifestations. 

The  patient's  condition  remained  almost  stationary  for  about  three 
months.  After  that,  gradually,  attention  improved,  memory  was 
restored,  the  pseudo-reminiscences  became  more  rare  and  were  spon- 
taneously corrected.  Finally  at  the  end  of  six  months  he  could  be 
considered  convalescent,  there  remaining  but  occasional  vertigo,  a 
certain  mental  and  physical  fatigability,  and  an  amnesic  gap  commenc- 
ing very  sharply  a  few  instants  before  the  accident  and  ending  imper- 
ceptibly somewhere  in  the  course  of  the  second  month  by  giving 
place  to  some  fragmentary  and  vague  recollections  which  grew  grad- 
ually more  complete  and  more  precise. 

Traumatic  Constitution. — This  is  the  commonGst  of  the 
above  mentioned  mental  residuals  which  may  persist  after 
recovery  from  traumatic  delirium;  it  is  also  frequently 
found  in  cases  in  which  no  delirium  at  all  has  developed 
after  the  initial  coma  or  stupor.  The  condition  has  been 
well  described  by  Koppen  ^  as  one  of  irritability,  forgetful- 

lArch.  f.  Psychiatric,  Vol.  XXXIII.  Quoted  by  Adolf  Meyer. 
The  Anatomical  Facts  and  Clinical  Varieties  of  Traumatic  Insanity. 
Amer.  Journ.  of  Insanity,  Jan.,  1904. 


TRAUMATIC  EPILEPSY  417 

ness,  diminished  working  capacity,  inability  to  concentrate 
attention,  and  increased  siisceptil^ility  to  alcohol.  "  The 
formerly  good-natured  or  even-tempered  persons  become 
irascible,  hard  to  get  along  with;  formerly  conscientious 
fathers  cease  to  care  for  their  family."  The  forgetfulness 
may  be  so  marked  that  "  frequently  everything  must  be 
written  down."  "  These  patients  are  unable  to  concentrate 
their  attention  even  in  occupations  which  serve  for  mere 
entertainment,  such  as  reading  and  playing  cards.  They 
like  best  to  brood  unoccupied;  even  conversation  is  rather 
obnoxious.  This  point  is  so  characteristic  that  it  gives  a 
certain  means  of  distinction  from  simulation,  which  as  a 
rule  does  not  interfere  with  taking  part  in  the  conversations 
and  pleasures  of  the  ward  and  playing  at  cards  which  means 
as  a  rule  too  much  of  an  effort  for  the  brain  of  actual  suffer- 
ers." Physically  there  are  apt  to  be  pain  or  feeling  of 
pressure  in  the  head  and  a  tendency  toward  dizziness.  "  Ex- 
cessive sensitiveness  of  their  head  obliges  them  to  avoid 
all  work  which  is  connected  with  sudden  jerks;  bending 
over  is  especially  troublesome;  and  there  is  hardly  any 
physical  work  in  which  this  can  be  avoided;  the  blood 
rushes  to  the  head,  headache  increases,  dizziness  sets  in, 
and  the  work  stops.  Patients  feel  best  when  in  the  open 
air,  inactive,  and  undisturbed." 

Traumatic  Epilepsy. — In  many  cases  ordinary  epilepsy 
is  wrongly  attributed  to  an  obviously  inadequate  trau- 
matism. However,  the  existence  of  true  traumatic  epilepsy 
is  hardly  to  be  questioned.  The  seizures  may  be  slight,  or 
partial,  or  Jacksonian,  or  without  complete  loss  of  conscious- 
ness, or,  on  the  contrary,  exactly  like  those  of  idiopathic 
epilepsy;  the  intervals  at  which  they  occur  are  variable; 
they  may  come  on  spontaneously  or  only  following  physical 
exertion,  indulgence  in  alcohol,  or  febrile  or  gastro-intestinal 
ailments.  The  mental  condition  is  apt  to  be  much  like  the 
above  described  traumatic  constitution  with  the  addition 
of  confused  or  delirioid  states  occurring  in  connection  with 
seizures;  in  cases  with  frequent  seizures  there  is  apt  to  be  a 


418  TRAUMATIC  DISORDERS 

slowly  progressive  deterioration  like  that  of  idiopathic 
epilepsy. 

Traumatic  Dementia. — This  consists  mainly  in  an  ex- 
aggeration of  the  memory  and  attention  defects,  general 
incapacitation,  and  loss  of  interests  characterizing  the  above 
described  traumatic  constitution. 

Aphasia,  deafness,  paralysis,  and  other  neurological 
symptoms,  depending  on  the  localization  of  the  brain 
injury,  may,  of  course,  also  be  observed. 


CHAPTER  XVII 

MISCELLANEOUS  GROUPS 

DELIRIA  OF  INFECTIOUS  ORIGIN  i 

The  mental  disorders  which  appear  in  the  course  of 
infectious  diseases  are  brought  about  by  the  combined 
action  of  several  factors:  elevation  of  temperature,  con- 
gestion of  the  nervous  centers,  and  poisoning  of  these  centers 
by  microbic  toxins.  The  most  important  factor  appears  to 
be  the  poisoning  of  the  nervous  centers. 

One  cannot  fail  to  notice  the  striking  clinical  resemblance 
existing  between  toxic  deUria  and  infectious  deliria;  in- 
deed the  resemblance  is  so  close  that  without  the  somatic 
symptoms  peculiar  to  each  condition  it  would  be  difficult 
or  even  impossible  to  make  the  differentiation.  Notes  on 
such  cases  almost  always  describe  the  same  symptoms: 
clouding  of  consciousness,  confusion,  numerous  illusions 
and  hallucinations,  motor  agitation. 

Moreover,  the  infection  itself,  independently  of  hyper- 
pyrexia and  probably  of  any  meningeal  lesion,  may  cause 
grave  mental  disorders  (infectious  deUrium  proper)  which  can 
only  be  explained  by  a  toxic  action. 

Febrile  Delirium. — In  the  mental  disorders  of  febrile 
origin  three  degrees  of  intensity  can  be  schematically  dis- 
tinguished. 

In  the  slightest  degree  of  intensity  the  disorder  is  limited 
to  slight  mental  torpor  and  irritahility. 

In  the  second  degree  there  is  disturbance  of  ideation. 

^  Klippel  et  Lopez.  Du  reve  et  du  delire  qui  lui  fait  suite  dans  les 
infections  aigues.  Rev.  de  Psychiatrie,  April,  1900. — Desvaux.  Delire 
dans  les  maladies  aigues.     These  de  Paris,  1899. 

419 


420  MISCELLANEOUS  GROUPS 

The  remarks  of  the  patient  become  discomiected,  and  are 
characterized  hj  a  pecuhar  monotony  suggestive  of  a  fixed 
idea.  Ten  times  in  succession  he  vdll  ask  whether  the  cup- 
board is  properly  locked,  or  whether  such  and  such  a  matter 
has  been  attended  to,  or  whether  some  particular  note  has 
been  duly  paid.  At  the  same  time  some  illusions,  chiefly 
affecting  %-ision,  make  their  appearance.  It  seems  to  the 
patient  that  someone  is  hiding  behind  the  curtains,  that 
the  fm-nitm-e  in  the  room  has  assumed  pecuhar  shapes.  He 
does  not  recognize  the  voices  of  those  about  him  and  con- 
founds them  with  one  another.  All  these  phenomena  the 
patient  is  more  or  less  conscious  of.  He  realizes,  either 
spontaneously  or  from  the  remarks  made  by  those  about  him, 
that  he  is  mistaken,  "  that  he  is  ra^dng,  that  he  no  longer 
knows  what  he  is  talking  about."  He  is  in  a  state  of  inde- 
finable uneasiness  and  is  apt  to  become  somewhat  restless, 
especially  at  night.  He  feels  ill  at  ease  in  his  bed,  tosses 
from  side  to  side,  asks  to  get  up. 

Finally,  in  the  tMrd  degree  of  intensity  we  have  true 
delirium.  This  consists  essentially  in  more  or  less  profound 
clouding  of  consciousness  combined  with  vague  delusions, 
multiple  psycho-sensory  disorders,  and  motor  excitement  which 
is  at  times  very  marked. 

The  delirium  is  essentially  variable  and  mobile,  at  time 
pleasant,  at  others  painful;  the  psycho-sensoiy  disturbances 
are  of  the  combined  form  with  a  predominance  of  illusions  and 
hallucinations  of  sight.  Images  and  scenes  follow  one 
another  as  in  a  dream,  of  which  they  seem  to  be  a  continua- 
tion (dream  dehrium).  The  patient  imagines  he  is  in 
the  country,  in  a  theater,  in  a  church;  pompous  processions 
march  past  him  amidst  the  sounds  of  music  and  the  perfume 
of  flowers  and  censers;  he  converses  with  imaginary  persons, 
defends  himself  against  assassins,  rejects  a  glass  of  milk 
offered  him,  thinking  that  it  is  poison.  Often  under  the 
influence  of  his  hallucinations  he  strikes  at  the  air  and 
attempts  to  get  out  into  the  street  or  to  pass  through  the 
window,  which  he  takes  for  the  door. 


INFECTIOUS   DELIRIUM  421 

However,  as  during  a  dream,  the  subject  may  by  a  sudden 
and  energetic  call  be  transported  from  his  imaginary  world 
into  the  real  one.  Such  periods  of  lucidity  are  in  general 
but  transitory. 

Often,  chiefly  in  the  beginning  of  all  forms  and  through 
the  entire  course  of  the  mild  forms,  the  delirium  disappears 
in  the  morning  to  reappear  in  the  evening  and  to  last  during 
a  portion  of  the  night. 

The  prognosis  depends  less  upon  the  intensity  of  the 
delirium  than  upon  the  physical  symptoms  which  accom- 
pany it.  As  a  rule  all  febrile  affections  comphcated  by 
intense  delirium  should  be  considered  grave. 

In  fatal  cases  the  delirium  gradually  subsides  and  coma 
replaces  the  excitement. 

Febrile  delirium,  like  acute  alcoholic  intoxication,  is  an 
excellent  criterion  for  judging  the  resistance  of  the  psychic 
organization:  the  greater  the  predisposition  to  mental 
disorders  the  more  likely  it  is  for  delirium  to  occur  under 
such  circumstances.  Like  alcohol,  microbic  poisons  and 
toxic  products  of  the  organism  affect  most  readily  minds 
the  equilibrium  of  which  is  least  stable  and  therefore  most 
easily  disturbed. 

The  treatment  is  that  of  the  infectious  disease.  Strict 
watching  is  indicated.  Cold  baths  are  often  very  efficacious 
in  relieving  the  mental  disorders. 

Infectious  Delirium  Proper. — Kraepelin  and  Aschaffen- 
burg  have  described  under  the  name  of  infectious  delirium 
mental  disorders  which  supervene  in  the  course  of  an  infec- 
tion without  the  fever  being  particularly  intense  or  even 
before  any  fever  has  appeared  {Initial  delirium). 

Infectious  delirium  is  met  with  chiefly  in  typhoid  fever, 
in  variola,  and  in  typhus  fever.  The  symptoms  sometimes 
take  the  form  of  maniacal  excitement,  more  often  that  of 
an  acute  confusional  state  or  of  hallucinatory  delirium. 


CHAPTER  XVIII 
MISCELLANEOUS  GROUPS  {Continued) 

PSYCHOSES  OF  EXHA  USTION:  PRIMARY  MENTAL 
CONFUSION,  ACUTE  DELIRIUM 

Well  described  by  Georget  and  by  Delasiauve,  primary 
mental  confusion  has  only  recently  been  brought  again  into 
prominence  in  French  medical  literature  through  the  labors 
of  Chaslin  and  of  Seglas.^ 

The  fundamental  element  of  this  morbid  entity  is  mental 
confusion  which  is  primary,  profound,  and  constant. 

Essential  Symptoms. — ^After  several  days  of  ill-defined 
prodromata  such  as  headache,  anorexia,  and  change  of 
disposition,  the  disease  sets  in,  manifesting  itself  by  psychic 
and  physical  symptoms. 

A.  Psychic  Symptoms. — These  are  the  symptoms  of 
intellectual  confusion,  more  or  less  marked  and  more  or  less 
pure  according  to  the  gravity  of  the  disease : 

Clouding  of  consciousness; 

Impairment  of  attention; 

Sluggish  and  disordered  association  of  ideas; 

Insufficiency  of  perception ; 

Aboulia,  characterized  by  constant  indecision  and  by 
slowness  and  uncertainty  of  the  movements. 

The  state  of  the  automatic  psychic  functions  varies 
according  to  the  form  of  the  disease:  mental  automatism 
may  be  relatively  unaffected  (simple  mental  confusion), 
exaggerated  (delirious  mental  confusion),  or  paralyzed,  like 

^  Chaslin.  La  confusion  mentale  primitive. — S6glas.  Legons  cli- 
niques. 

432 


PRIMARY  MENTAL  CONFUSION  423 

the  higher  mental  functions  (mental  confusion  of  the  stupor- 
ous form). 

B.  Physical  Symptoms. — The  physical  symptoms  are 
constant  and  "  are  the  expression  of  the  general  prostra- 
tion, exhaustion,  and  malnutrition  "  (Seglas). 

Loss  of  flesh  is  an  early  and  a  very  m.arked  symptom. 
It  is  caused  by  insufficient  alimentation,  digestive  dis- 
orders, and  defective  assimilation. 

Fever  sometimes  exists,  chiefly  at  the  onset;  in  some 
cases,  especially  in  the  stuporous  form,  there  may  be  sub- 
normal temperature. 

A  small  low  tension  pulse,  feeble  and  at  times  irregular 
heart  sounds,  sluggishness  of  the  peripheral  circulation, 
cyanosis  of  the  extremities,  and  oedema  are  among  the  mani- 
festations of  the  general  atony  of  the  cardiovascular  ap- 
paratus. 

Appetite  is  lost,  the  tongue  coated;  the  process  of  diges- 
tion is  accompanied  by  painful  sensations;  constipation  is 
often  present  and  is  very  obstinate. 

Frequently  there  is  slight  albuminuria.  The  toxicity 
of  the  urine  is  often  increased,  this  being  dependent  on  the 
presence  of  certain  ptomaines  in  the  urine  (Ballet  and 
Seglas) } 

Sleep  is  diminished,  often  replaced  by  a  dreamy  state 
analogous  to  that  of  the  infectious  diseases. 

Primary  mental  confusion  may  be  met  with  in  four 
principal  forms,  differing  in  their  gravity  and  in  the  pre- 
dominance of  one  or  another  class  of  symptoms: 

Simple  mental  confusion; 

Delirious  mental  confusion; 

Stuporous  mental  confusion; 

Hyperacute  mental  confusion  (acute  delirium). 

Simple  Form. — The  essential  symptoms  which  have 
been    enumerated    above    are    encountered    here    in  their 

1  For  a  bibliography  bearing  on  the  changes  in  the  urine  in  mental 
confusion  and  in  the  psychoses  in  general,  see  Ballet.  Les  psychoses. 
(Article  in  Traite  de  Medecine,  edited  by  Charcot,  Bouchard  and  Bris- 
saud.)     Chapters  on  Melancholia  and  Mental  Confusion. 


424  MISCELLANEOUS  GROUPS 

purest  form.  The  phenomena  of  psychic  paralysis  are  of 
a  moderate  degree  ot  intensity  and  the  automatic  mental 
functions  are  unaffected. 

The  patient  is  often  more  or  less  conscious  of  his  con- 
dition; he  observes  that  a  change  has  taken  place  in  him. 
"  I  am  losing  my  head.  .  .  .  My  mind  is  a  blank.  .  .  ." 
He  perceives  his  mental  disability  and  complains  of  being 
unable  to  gather  or  direct  his  thoughts  or  to  evoke  remi- 
niscences— even  of  events  that  have  left  a  very  strong  im- 
pression. 

The  indecision  and  insufficiency  of  perception  bring 
about  a  state  of  constant  bewilderment.  The  patient  keeps 
repeating  the  same  questions  and  the  same  exclamations: 
"  Who  is  there?  .  .  .  Who  has  come?  .  .  .  Who  are 
you?  .  .  .  Everything  around  me  has  changed."  He  does 
not  recognize  his  surroundings,  or  if  he  does,  it  is  with  un- 
certainty. He  is  not  sure  of  the  identity  of  those  about 
him;  his  bed  appears  queer,  his  own  body  seems  to  be 
changed,  scarcely  recognizable.  It  seems  that  his  per- 
sonality is  going  to  pieces  so  that  he  no  longer  recognizes 
himself.  The  notion  of  time  is  impaired.  The  patient 
cannot  tell  whether  he  has  been  at  the  hospital  a  day  or  a 
week.  In  other  words  the  patient's  orientation  suffers  in  all 
its  elements:  allopsychic,  autopsychic,  and  temporal.  The 
disorientation  is  generally  more  marked  when  the  patient 
is  away  from  his  habitual  surroundings.  While  surrounded 
by  familiar  persons  and  objects,  the  patient  orients  himself 
more  or  less  automatically,  in  a  new  place  he  could  find 
his  bearings  only  by  a  series  of  mental  operations  of  which 
he  is  no  longer  capable. 

The  reactions  are  slow,  undecided;  the  movements 
awkward  and  clumsy. 

The  mental  automatism  remaining  intact,  those  mental 
operations  which  require  no  effort  and  no  intervention  of  the 
will  can  still  be  properly  performed.  Thus  one  may  obtain 
from  the  patient  a  certain  number  of  relevant  and  accurate 
replies  to  questions  concerning  his  age,  occupation,  residence, 


PRIMARY  MENTAL  CONFUSION  425 

etc.  But  these  replies  are  always  given  mechanically; 
they  are  brief  and  abrupt,  and  can  be  elicited  only  by  putting 
the  questions  energetically  and  concisely. 

This  simple,  and,  so  to  speak,  schematic  form  of  primary 
mental  confusion  is  uncommon. 

Delirious  Form. — This  form,  much  more  frequent  than 
the  preceding  one,  owes  its  peculiar  aspect  to  a  more  or 
less  marked  exaggeration  of  the  activity  of  the  mental 
automatism,  which  gives  rise  to:  (a)  flight  of  ideas  and 
incoherence;  (6)  delusions  and  psycho-sensory  disorders; 
(c)  more  or  less  motor  excitement. 

The  delusions  present  no  systematization,  as  for  this 
at  least  a  relative  lucidity  is  necessary.  They  assume 
different  forms,  which  often  change;  ideas  of  grandeur, 
transformation  of  personality,  melancholy  ideas,  ideas  of 
persecution.  Painful  delusions  are  the  most  common. 
Sometimes  the  ideas  are  absurd,  like  those  of  senile  dements 
or  of  general  paralytics. 

The  psycho-sensory  disorders  consist  sometimes  in  agree- 
able, but  more  often  in  painful,  illusions  and  hallucina- 
tions of  all  the  senses,  though  most  often  of  vision  and  of 
hearing.  They  may  combine  so  as  to  create  an  imaginary 
world  which  is  mobile  and  changeable,  or,  on  the  contrary, 
they  may  exist  together  without  any  apparent  correlation. 

Occasionally  the  incessant  illusions  and  hallucinations 
impart  to  the  patient  a  peculiar  expression.  Most  cases 
described  under  the  name  of  hallucinatory  delirium  should 
properly  be  included  in  this  form  of  mental  confusion. 

The  emotional  tone  is  variable,  governed  to  some  extent 
by  the  delusions.  However,  one  often  finds,  in  spite  of 
very  active  delirium,  a  striking  indifference,  so  that  a  certain 
discord  exists  between  the  delusions  and  the  emotions. 

The  motor  excitement  is  not  always  due  to  delusions  or 
psycho-sensory  disturbances.  As  in  dementia  praeccx,  so 
also  in  this  condition  the  patient  may  give  vent  to  cries 
and  motor  discharges  that  are  purely  automatic  and  without 
any  apparent  purpose. 


426  MISCELLANEOUS  GROUPS 

Stuporous  Form. — Here  the  psychic  paralysis  involves 
not  only  the  higher  mental  faculties,  but  also  the  auto- 
matic functions. 

The  limbs  are  motionless,  the  eyes  dull,  and  the  face 
expressionless;  the  mouth  may  be  half  open  and  the  saliva 
dribbling  away  uncontrolled.  The  patient  fails  to  react 
even  to  the  strongest  stimulation,  or  he  may  react  but  very 
feebly. 

Cataleptic  attitudes  with  dilated  pupils  are  frequently 
seen. 

H3rperacute  Form  (Acute  Delirium). — This  form  is  char- 
acterized by  special  intensity  of  the  delirium  and  motor 
excitement,  and  by  great  gravity  of  the  general  symptoms. 

The  patient,  assailed  by  numerous  hallucinations, 
either  painful,  or  agreeable  and  accompanied  by  erotic 
tendencies,  becomes  completely  disoriented  and  wildly 
excited:  he  shouts,  sings,  jumps  out  of  bed,  strikes  the 
walls,  and  attacks  those  about  him.  The  eyes  are  injected, 
respiration  is  panting,  skin  covered  with  perspiration, 
temperature  high,  and  the  pulse  small  and  often  rapid  and 
irregular.  These  signs  point  to  the  general  gravity  of  the 
condition.  In  fatal  cases  the  patient  rapidly  passes  into 
coma  and  dies  in  a  few  days.  In  favorable  cases  the  agita- 
tion gradually  disappears,  the  patient  regains  his  sleep,  and 
recovery  finally  takes  place;  this  favorable  termination  is  rare. 

Duration,  Course,  and  Prognosis  of  Primary  Mental 
Confusion. — The  duration  of  the  attack  varies  from  several 
days  to  a  few  months.  The  curve  representing  its  intensity 
is  rapidly  ascendant,  then  it  remains  stationary  for  some 
time  with  some  oscillations,  and  finally  descends  gradually. 
The  period  of  descent  often  presents  irregularities  on  account 
of  recrudescences  of  the  disease,  which  are  usually  mild. 

Such  is  the  course  of  favorable  cases,  which  fortunately 
are  the  most  frequent  (excluding  acute  delirium).  Recovery 
is  complete.  But  the  patient's  recollection  of  the  events 
which  have  taken  place  during  his  illness  is  vague  or  even 
absent.     The  period  of  convalescence  is  protracted. 


PRIMARY  MENTAL  CONFUSION  427 

Suicide  is  rare  even  in  the  depressed  forms;  the  aboulia 
is  the  patient's  safeguard. 

In  unfavorable  cases  death  occurs  from  collapse  in  the 
hyperacute  form,  and  from  cachexia  or  from  some  com- 
plication (pneumonia,  subacute  tuberculosis,  influenza, 
infections  following  traumatisms)  in  the  less  rapid  cases. 

Diagnosis. — The  principal  elements  of  diagnosis  are: 
appearance  of  mental  confusion  at  the  onset;  possibility  of 
obtaining  correct  replies  to  simple  and  energetically  put 
questions;  state  of  physical  exhaustion,  and  existence  of  the 
special  etiological  factors,  which  we  shall  mention  farther  on. 

Pathological  Anatomy. — The  lesions  of  primary  mental 
confusion  are  of  two  kinds :  inflammatory  and  degenerative. 
The  former,  which  are  most  prominent  in  the  severe  cases, 
consist  in  congestion  and  diapedesis  in  the  nervous  centers. 
The  latter  are  more  constant,  and  consist  in  degeneration 
of  the  nerve-cells,  which  is  demonstrable  by  Nissl's  method.^ 

Etiology. — All  factors  capable  of  bringing  about  rapid 
and  profound  exhaustion  of  the  organism  occur  in  the 
etiology  of  primary  mental  confusion:  physical  and  mental 
stress,  painful  and  prolonged  emotions,  but  especially  grave 
somatic  affections.  The  puerperal  state,  through  the  ex- 
haustion which  it  entails  as  well  as  through  the  nutritive 
disorders  and  infections  by  which  it  is  sometimes  compli- 
cated; the  infectious  diseases  (typhoid  fever,  the  eruptive 
fevers,  influenza,  cholera);  profuse  hemorrhages;  inanition, 
etc.,  are  among  the  causes  frequently  found  in  the  history  of 
the  disease.  ' 

How  is  the  action  of  these  factors  to  be  explained?  Two 
hypotheses  are  possible. 

According  to  one,  that  of  Binswanger,  the  general  ex- 
haustion  of  the   organism   brings   about   deficient  cerebral 

^  Ballet  et  Faure.  Contribution  a  V anatomie  pathologique  de  la 
psychose  polynevritique  et  certaines  formes  de  confusion  mentale  primitive. 
Presse  med.,  Nov.,  30,  1898. — Maurice  Faure.  Sur  les  lesions  cellu- 
laires  corticales  observees  dans  six  cas  de  troubles  mentaux  toxi-infectieux. 
Rev.  neurol.,  Dec,  1899. 


428  MISCELLANEOUS  GROUPS 

nutrition  the  clinical  expression  of  which  is  primary  mental 
confusion. 

According  to  the  other,  advanced  by  Kraepelin,  the  causes 
enumerated  above  bring  about  disturbances  in  the  nutritive 
changes  and  determine  the  production  of  toxic  substances 
which,  acting  upon  the  cerebral  cells,  give  rise  to  an  intoxi- 
cation psychosis:  primary  mental  confusion. 

Perhaps  both  causes  are  at  work  simultaneously.  In 
either  case  exhaustion  constitutes  the  essential  cause  of  the 
affection  and  the  term  "  Exhaustion  Psychosis  "  is  therefore 
perfectly  apphcable  to  it. 

Treatment. — During  the  entire  acute  period  of  the 
disease  rest  in  bed  should  be  rigorously  enforced. 

Proper  alimentation  is  of  great  importance.  A  recon- 
structive diet  better  than  all  medication  sustains  the  patient's 
strength  and  even  calms  the  agitation.  Milk,  eggs,  chopped 
meat,  and  meat-juice  should  form  the  basis  of  the  diet. 

In  cases  of  refusal  of  food  one  must  resort  without 
hesitation  to  artificial  feeding;  these  patients  cannot  with 
impunity  be  allowed  to  fast.  Gastric  lavage  sometimes 
gives  good  results,  even  in  cases  of  acute  delirium. 

Injections  of  saline  solution  are  of  great  service  and 
easy  of  application.  The  necessary  apparatus  consists 
chiefly  of  a  glass  funnel,  a  soft-rubber  tube,  and  a  slender 
trochar. 

Ordinarily  300-500  grams  of  normal  saline  solution  may 
be  injected  every  day  or  every  second  day. 

The  most  important  results  of  this  treatment  are  elevation 
of  blood  pressure  and  diuresis.^ 

Moderate  physical  exercise,  life  in  the  open  air,  reading, 
and  light  mental  work  for  brief  periods  at  a  time  accelerate 
the  course  of  convalescence. 

1  Cullerre.  De  la  transfusion  sereuse  sous-cutanee  dans  les  psychoses 
aigues  avec  auto-intoxication.  Presse  med.,  Sept.  30,  1899. — Jacquin. 
Du  serum  artificiel  en  Psychiatric.  Ann.  naed.  psych.,  May-June, 
1900. 


CHAPTER  XIX 

MISCELLANEOUS  GROUPS  {Continued) 
PSYCHOSES  OF  AUTOINTOXICATION:  UREMIC  DELIRIUM 

URiEMic  delirium  presents  the  usual  features  of  toxic 
deliria:  more  or  less  complete  clouding  of  consciousness, 
disorientation,  phenomena  of  psychic  automatism,  among 
which  psycho-sensory  disorders  occupy  a  prominent  position. 

The  delusions,  the  emotional  tone,  and  the  reactions 
enable  us  to  distinguish  two  principal  forms  of  ursemic 
delirium:  an  expansive  form  and  a  depressed  form. 

Expansive  Form. — The  patient  is  a  great  personage,  a 
general,  a  prince;  he  assists  at  a  grand  review,  gives  com- 
mands to  his  officers,  or  orders  sixteen  horses  to  be  harnessed 
to  his  carriage;  the  Pope  presents  him  with  the  imperial 
crown. 

Often  the  delirium  takes  a  mystic  form:  the  heavens 
open,  celestial  music  is  heard,  or  angels  descend  on  an  im- 
mense ladder  as  in  Jacob's  dream. 

Depressed  Form. — Melancholy  ideas  combine  with  ideas 
of  persecution  and  hallucinations  of  an  unpleasant  cfiaracter. 
The  patient  imagines  people  are  searching  for  him  to  drag 
him  to  the  scaffold;  the  house  is  on  fire;  an  odor  of  sulphur 
is  diffused  through  the  air. 

Whatever  the  form  of  delirium,  the  reactions  often  rise 
to  violent,  at  times  terrible,  agitation.  Often,  also,  in  the 
depressed  and  mystic  forms,  there  is  marked  stupor  with  a 
tendency  to  cataleptoid  attitudes.^ 

1  Brissaud.  De  la  catatonie  brightique.  Sem.  med.,  1893. — CuUerre. 
Sur  un  ca^  de  folie  uremique  conseculif  a  un  retrecissement  traumatique 
de  I'urethre.     Arch,  de  neurol.,  Vol.  XXVII,  No.  89. 

429 


430  MISCELLANEOUS  GROUPS 

As  to  the  development  of  the  attack,  we  distinguish  an 
acute  form  characterized  by  severe  symptoms:  intense 
agitation  or,  on  the  contrary,  profound  stupor,  incessant 
hallucinations,  extreme  confusion  with  clouding  of  conscious- 
ness, etc.;  and  a  subacute  form  characterized  by  sjnnptoms 
of  lesser  intensity  and  by  periods  of  comparative  lucidity 
alternating  with  delirious  periods. 

In  some  exceptional  cases  of  subacute  form  the  delusions 
become  systematized  and  may  thus  be  misleading  in  the 
diagnosis. 

The  mental  symptoms  of  ursemic  delirium  present  no 
pathognomonic  features  and  are  merely  a  manifestation  of 
poisoning  of  the  cerebral  cells.  The  diagnosis  must  be  made 
from  the  accompanying  somatic  symptoms:  convulsive  at- 
tacks, cardiovascular  disorders,  dyspnoea,  oedema,  pupillary 
manifestations — myosis  and  paresis  of  the  pupils — diminu- 
tion of  the  specific  gravity  and  of  the  toxicity  of  the 
urine,  albuminuria,  anuria,  oliguria,  or  polyuria. 

Ursemic  delirium  is  often  very  similar  to  delirium  tre- 
mens. It  seems  that  the  two  affections  may  even  be  com- 
bined. Brault  1  is  of  the  opinion  that  uraemia,  like  trau- 
matism or  pneumonia,  may  act  as  the  exciting  cause  of  an 
attack  of  delirium  tremens.  We  have  already  seen  how 
much  importance  is  attributed  by  some  authors,  notably 
Herz,  to  uraemia  as  a  pathogenic  factor  in  delirium  tremens. 

The  prognosis  depends  upon  the  severity  of  the  somatic 
disturbances. 

The  treatment  is  that  of  uraemia  in  general:    milk  diet 
blood-letting,  purgatives,  and  diaphoretics. 

^  Traite  de  mededne.    Charcot-Bouchard.    Maladies  des  reins. 


CHAPTER  XX 

MISCELLANEOUS  GROUPS  {Continued) 

THYROGENIC  PSYCHOSES 

HYPOTHYROIDISM:    MYXCEDEMA;    CRETINISM.— HYPER- 
THYROIDISM: EXOPHTHALMIC  GOITER 

Destruction  of  the  thyroid  gland  gives  rise  to  pecuHar 
autointoxication  which  is  met  with  in  two  cHnical  forms: 
myxcedema  and  cretinism:  in  the  former  the  destruction  of 
the  gland  occurs  at  an  adult  age,  in  the  latter  it  occurs  in 
infancy. 

§  1.    Myxcedema 

The  external  aspect  of  a  myxoedematous  patient  is 
characteristic.  The  puffed  and  expressionless  face  together 
with  the  general  attitude  reflect  both  mental  inertia  and 
profound  disorder  of  general  nutrition. 

Psychic  Disturbances. — These  consist  chiefly  in  symp- 
toms indicating  a  Uunting  and  torpor  of  cerebral  activity 
— psychic  paralysis;  there  is  extreme  sluggishness  of  asso- 
ciation of  ideas  demonstrable  by  simple  clinical  examina- 
tion as  well  as  by  psychometry;  the  attention  is  difficult  to 
obtain  and  to  fix;  there  are  also  retrograde  amnesia  by 
default  of  reproduction  and  anterograde  amnesia  by  default 
of  fixation;   permanent  indifference;   aboulia. 

The  indifference  is  occasionally  interrupted  by  transient 
attacks  of  irritability.  Myxoedematous  patients  are  often 
sulky  and  ill-natured. 

Physical  Disturbances. — Sleep  is  diminished,  replaced  by 
permanent  somnolence,  and  disturbed  by  nightmares. 

431 


432  MISCELLANEOUS  GROUPS 

The  reflexes  are  diminished  or  abolished;  all  move- 
ments are  sluggish  and  clumsy. 

But  the  most  striking  changes  are  those  of  the  integu- 
ments and  of  the  thyroid  gland. 

Integuments. — The  skin  is  thickened ,  and  infiltrated; 
its  surface  is  smooth  and  of  a  dull  whiteness.  On  palpation 
it  gives  the  sensation  of  waxy  tissue.  There  is  no  pitting 
on  pressure,  this  being  a  point  of  distinction  between  myx- 
oedematous  infiltration  and  anasarca. 

The  features  are  dull,  eyes  sunken,  lips  thickened;  the 
wrinkles  of  the  forehead  disappear,  and  the  naso-labial  folds 
become  effaced.  The  physiognomy  is  immovable  and  stupid. 
The  hair  of  the  head,  eyebrows,  and  beard  is  scant,  discolored, 
and  atrophied.  These  characteristics  are  pathognomonic 
of  the  myxoedematous  facies. 

The  hair  over  the  entire  body  is  atrophied.  The  nails 
become  deformed  and  brittle. 

The  mucous  membranes  present  thickening  analogous 
to  that  of  the  skin.  They  are  pale,  anaemic,  and  in  places 
cyanotic. 

Thyroid  Gland. — On  palpation  one  finds  atrophy  or  even 
complete  absence  of  the  gland. 

Sometimes  the  thyroid  gland  is  increased  in  size,  causing 
an  abnormal  prominence  in  front  of  the  neck.  This  hyper- 
trophy, true  or  false,  is  generally  transitory,  and  occurs 
chiefly  in  the  early  stages  of  the  disease.  When  the  swelling 
persists  through  the  entire  duration  of  the  affection,  it  is 
usually  the  result  of  cystic  degeneration  of  the  gland. 

The  visceral  disorders  are  not  characteristic;  they 
indicate  general  atony  and  diminished  vitality  of  the  organ- 
ism: small,  compressible  pulse,  sluggish  and  painful  diges- 
tion, and  constipation. 

The  course  of  myxcedema  is  progressive,  but  interrupted 
by  frequent  remissions. 

If  no  appropriate  treatment  is  instituted,  the  stock  of 
ideas  becomes  diminished,  psychic  inertia  becomes  extreme 
and  complete  dementia  is  established ;  also  the  physical  symp- 


CRETINISM  433 

toms  become  accentuated  and  death  supervenes  either  from 
cachexia  or  from  some  compHcation  (pulmonary  tuber- 
culosis) . 

Treatment. — It  is  possible  to  supply,  to  a  certain  extent, 
the  deficiency  caused  by  atrophy  of  the  thyroid  gland  by  the 
administration  of  the  thyroid  substance  of  animals  (almost 
exclusively  that  of  the  sheep),  either  in  the  crude  form  or 
in  the  form  of  pharmaceutical  preparations.  The  thyroid 
substance  may  be  administered  in  tablets,  pills,  or  capsules 
containing  it  either  in  the  fresh  state  or  dried  and  reduced 
to  a  powder. 

A  glycerine  extract  of  thyroid  gland  is  also  prepared  and 
is  known  by  the  name  of  thyroidine. 

Finally,  Baumann  and  Proos  have  extracted  from  the 
sheep's  thyroid  a  substance,  iodothyrine,  which  seems  to  be 
the  active  principle.  This  substance  is  "  triturated  with 
sugar  of  milk  in  such  proportions  that  1  gram  of  the  mixture 
represents  1  gram  of  the  fresh  gland."  ^ 

Thyroid  medication  must  be  employed  with  great 
caution.  Toxic  symptoms  are  easily  produced:  accelera- 
tion of  the  pulse  and  respiration,  headache,  attacks  of 
vertigo,  and,  in  severe  cases,  a  tendency  to  collapse.  There- 
fore it  is  advisable  to  begin  the  treatment  with  small  doses, 
which  should  be  gradually  increased,  and  promptly  reduced 
or  suspended  entirely  on  the  appearance  of  alarming  symp- 
toms. 

The  mental  and  physical  effects  of  thyrotherapy  are 
very  rapid.  In  a  few  days  the  cerebral  torpor  becomes 
less  marked,  the  skin  reassumes  its  normal  aspect,  and 
the  other  myxoedematous  symptoms  become  abated. 

§  2.     Cretinism 

Cretinism  may  be  defined  as  an  arrest  of  somatic  and 
psychic  development  dependent  generally  upon  a  goiter, 
and  more  rarely  upon  simple  atrophy  of  the  thyroid  gland. 

1  Briquet.  Valeur  comparee  des  medications  thyroldiennes.  Presse 
medic,  1902,  No.  74. 


434  MISCELLANEOUS  GROUPS 

The  affection  occurs  endemically  in  mountainous  regions, 
such  as  the  Alps,  the  Rocky  Mountains,  the  high  plateaus  of 
Himalaya,  Black  Forest,  etc.,  and  sporadically  in  most  regions. 

Its  etiology  is  not  well  known.  Numerous  factors  are 
said  to  be  capable  of  causing  it:  atmospheric  humidity; 
certain  geological  compositions  of  the  soil  (cretinism  occurs 
.frequently  in  countries  where  the  soil  is  composed  of  schistose' 
clay  or  of  streaked  sandstone) ;  poor  quality  of  the  water, 
which  in  the  endemic  sections  is  poorly  aerated,  deprived 
of  iodine,  and  charged  with  calcium  and  magnesium  salts; 
want;   heredity. 

All  these  causes,  the  influence  of  which  should  be  kept 
in  view,  probably  only  prepare  the  soil  for  the  action  of  some 
specific  agent  still  unknown.  According  to  the  opinion  of 
Griesinger,  "  endemic  goiter  and  cretinism  are  specific  dis- 
eases produced  by  a  toxic  cause  of  miasmatic  nature." 

The  symptoms  of  cretinism  usually  appear  in  early 
childhood.  Sometimes  the  onset  is  acute,  so  that  the 
destruction  of  the  gland  is  accomplished  in  a  few  days. 
Such  was  the  case  reported  by  Shields,^  in  which  an  acute 
thyroiditis  caused  the  destruction  of  the  thyroid  gland 
and  resulted  in  cretinism. 

Much  more  frequently  the  process  is  insidious,  and  it 
is  impossible  to  ascertain  the  exact  date  of  onset. 

The  size  of  the  goiter  is  variable.  The  swelling  may 
be  sHght,  scarcely  perceptible,  or  so  enormous  as  to  com- 
pletely disable  the  patient.  Resulting  usually  from  a 
degeneration  of  the  thyroid  gland,  it  becomes  evident  at 
about  the  sixth  or  eighth  year  of  age  and  increases  up  to  the 
time  of  puberty  or  even  later. 

Simple  atrophy  of  the  gland  is  much  less  frequent  and 
is  seen  chiefly  in  sporadic  cases. 

Physically  the  cretin  exhibits,  in  addition  to  the  changes 
in  the  thyroid  gland,  the  following  symptoms:  the  stature 
is  below  the  normal;    the  face  is  pale,  puffed,  or  marked 

1 A  Case  of  Cretinism  Following  an  Attack  of  Acute  Thyroiditis. 
New  York  Med.  Jour.,  Oct.  1,  1898. 


HYPERTHYROIDISM  435 

precociously  with  senile  wrinkles;  the  pilous  system  is 
poorly  developed ;  the  mucous  membranes  are  pale,  anaemic, 
and  thickened;  the  teeth  are  abnormal  in  shape  and 
implantation  and  subject  to  caries;  puberty  is  retarded  or 
even  absent,  and  the  cretin  may  remain  infantile  all  his  life. 

Psychically  we  encounter  all  degrees  of  idiocy  and  im- 
becility. It  seems,  however,  that  the  cretin  is  less  impulsive, 
more  manageable,  and  more  capable  of  emotional  activity 
than  the  ordinary  idiot  or  imbecile.^ 

The  brains  of  cretins  present  no  known  specific  lesions; 
asymmetry  and  various  malformations  of  the  hemispheres 
are  frequent. 

The  treatment  ^  consists  in  thyroid  medication,  the  results 
of  which  are  the  more  perceptible  the  earlier  it  is  instituted. 

§  3.     Hyperthyroidism  :  Exophthalmic  Goiter 

In  1835  Graves,  a  Dublin  physician,  described  an  affec- 
tion characterized  by  exophthalmos,  swelling  of  the  thyroid 
gland,  and  tachycardia.  In  1840  Basedow,  in  Germany, 
more  fully  described  this  affection.  It  is  now  generally 
known  either  as  Grave's  disease,  Basedow's  disease,  or 
exophthalmic  goiter.  Its  underlying  disorder  seems  to  be 
an  overaction  of  the  thyroid  gland. 

In  addition  to  the  above-mentioned  syndrome  patients 
usually  present  more  or  less  marked  tremor,  excessive  per- 
spiration, especially  of  the  hands  and  feet,  and  they  often 
complain  of  palpitation  and  shortness  of  breath  which  is 
made  worse  by  exertion  or  excitement.  In  advanced  cases 
there  is  more  or  less  cachexia. 

This  affection  is  of  psychiatric  interest  because  the 
mental  condition  of  those 'afflicted  with  it  is,  as  a  rule,  far 
from  normal.  The  characteristic  mental  manifestations 
are:  restlessness;  a  state  of  feeing  "  on  edge,"  i.e.,  easily 
startled,  excited,  angered,  or  brought  to  tears;  anxiety; 
sleeplessness.  Very  severe  cases  are  sometimes  complicated 
with  delirium. 

1  Bourneville.     Progres  medical,  1897.  2  Ibid.,  1890. 


436  MISCELLANEOUS  GROUPS 

The  disease  varies  in  degree.  Some  cases  run  a  rapid 
course  toward  a  fatal  termination.  Others  are  characterized 
only  by  an  incomplete  syndrome,  such  as  moderate  tachy- 
cardia (pulse  100-110  per  minute  at  rest)  with  slight  tremor 
and  sweating  of  palms,  but  without  exophthalmos  and 
without  noticeable  enlargement  of  the  thyroid  gland. 
Obviously  it  would  hardly  be  proper  to  speak  of  such  cases 
as  exophthalmic  goiter.  Accordingly  they  are  generally 
spoken  of  as  hyperthyroidism.  But  they  may,  under 
certain  conditions,  develop  into  the  complete  syndrome. 
Other  cases,  again,  are  still  milder,  being  latent  under 
ordinary  conditions,  but  developing  characteristic  mani- 
festations of  hyperthyroidism  when  exposed  to  severe  and 
prolonged  stress. 

All  forms  of  hyperthyroidism  are  said  to  be  more  common 
in  women  than  in  men;  but  recruiting  experiences  in  the 
World  War  have  shown  that  it  was  more  common  than  had 
been  suspected  in  men  of  military  age  in  degrees  sufficient 
to  disqualify  for  military  service. 

Treatment. — Persons  liable  to  develop  hyperthyroidism 
on  exertion  should  select  a  sedentary  occupation  and  lead, 
as  far  as  possible,  a  life  free  from  excitement  or  strain. 

When  symptoms  of  hyperthyroidism  develop,  the  follow- 
ing measures  of  treatment,  mentioned  in  the  order  of  their 
importance  and  efficacy,  should  be  tried :  rest  in  bed,  includ- 
ing mental  rest,  i.e.,  freedom  from  worry  or  excitement; 
the  administration  of  belladonna  in  ascending  doses;  pos- 
sibly sodium  bromide  or  trional 

Cases  which  do  not  recover  sufficiently  under  the  above 
treatment  to  be  able  to  resume  at  least  light  work  should 
be  treated  surgically.  Partial  extirpation  of  the  thyroid 
gland  often  results  in  permanent  relief.  In  competent 
hands  and  in  cases  which  have  not  been  allowed  to  become 
too  far  advanced  the  operation  is  attended  with  but  little 
danger.^ 

1 C.  H.  Mayo.  Surgery  of  the  Thyroid.  Observations  on  Five 
Thousand  Operations.     Journ.  Amer.  Med.  Assn.,  July  5,  1913. 


CHAPTER   XXI 

MISCELLANEOUS  GROUPS  {Continued) 

MENTAL  DISORDERS  DUE  TO  ORGANIC  CEREBRAL  AFFEC- 
TIONS 

All  organic  cerebral  ajffections,  whether  diffuse  or  local- 
ized, have  an  influence  upon  the  psychic  functions. 

The  most  important  among  those  which  have  not  already- 
been  considered  are  tumors,  multiple  sclerosis,  brain  abscess, 
and  central  neuritis. 

Tumors,  when  small  and  of  slow  growth,  may  give  rise 
to  no  mental  symptoms.  In  other  cases  the  mental  state 
presents  certain  peculiarities  which  may  aid  in  the  diagnosis: 
Dupre  and  Devaux  ^  have  found  that  "  patients  suffering 
from  cerebral  tumor  present  a  peculiar  state  of  mental 
depression  and  enfeeblement,  which  constitutes  their  domi- 
nant psychopathic  note:  this  state  is  one  of  torpor,  psychic 
dullness,  and  clouding  of  the  intellect,  to  which  may  be  added 
mental  puerilism."  Properly  speaking  these  cases  present 
no  true  dementia  until  the  affection  has  reached  its  terminal 
period.  According  to  the  same  authors  ^  "  the  intelligence, 
though  clouded,  is,  however,  not  destroyed.  It  responds 
to  strong  stimuli,  to  imperious  injunctions;  it  is  veiled,  but 
nevertheless  present,  and  not  until  the  last  phases  of  the 
development  of  the  affection  does  it  decline  and  finally  dis- 
appear." 

^  Nouvelle  iconographie  de  la  Salpetriere.     Tumeur  cerebrale,  1901, 
Nos.  2  and  3,  p.  51. 
2  Loc.  cit,  p.  8. 

437 


438  MISCELLANEOUS  GROUPS 

The  diagnosis  of  brain  tumor  is  based  chiefly  on  the 
neurological  symptoms;  these  are  usually  classified  into 
cardinal  symptoms,  common  to  all  tumors  and  resulting 
from  increase  of  intracranial  pressure — severe  and  persistent 
headache,  slow  pulse,  vertigo,  vomiting,  and  gradual  im- 
pairment of  vision  due  to  optic  neuritis — and  focal  symptoms, 
varying  with  the  location  of  the  tumor — ^Jacksonian  epilepsy, 
monoplegia,  hemiplegia,  aphasia,  apraxia,  hemianopsia, 
oculo-motor  paralysis,  etc. 

The  differentiation  between  brain  tumor  and  general 
paralysis  may  present  considerable  difficulty,  the  more  so 
in  view  of  the  fact  that  in  the  case  of  tumors  involving 
the  meninges  the  cerebro-spinal  fluid,  as  in  general  paralysis, 
may  show  an  increase  of  cellular  elements.  The  applica- 
tion of  the  Wassermann  reaction  may  aid  materially  in  the 
diagnosis. 

Multiple  sclerosis  may  be  accompanied  by  a  gradually 
progressive  mental  deterioration  simulating  that  of  general 
paralysis.  In  such  cases  too  the  application  of  the  Wasser- 
mann reaction  may  aid  in  the  diagnosis. 

Brain  abscess  occurs  chiefly  as  a  complication  of  chronic 
purulent  otitis  media.  The  symptoms  are  slow  pulse, 
localized  headache,  fever  of  the  asthenic  type,  often  sub- 
normal temperature;  mentally  there  are  dullness,  confusion, 
restlessness,  and  in  severe  cases  coma.  The  abscess  is 
generally  located  either  in  the  temporal  lobe — when 
amnesic  aphasia  is  a  prominent  symptom  if  the 
lesion  is  on  the  left  side — or  in  one  cerebellar  hemi- 
sphere— causing  vomiting,  vertigo,  and  staggering  gait. 
The  diagnosis  rests  upon  a  history  of  chronic  otitis 
media,  the  symptoms  here  enumerated,  and  a  micro- 
scopical examination  of  the  blood  which  generally  reveals 
leucocytosis;  an  exploratory  operation  may  be  necessary 
and  should  be  done  early  in  every  case  in  which  this  con- 
dition is  suspected. 

Central  Neuritis. — Cases  of  this  highly  interesting 
though  rather  rare  condition  have  been  reported  by  Wigles- 


ORGANIC  CEREBRAL  AFFECTIONS  439 

worth/  Meyer,2  Worcester,^  Turner,'^  Cotton  and  Southard, ^ 
Somers  and  Lambert,^  and  others.  The  first  systematic 
clinical  and  anatomical  study  was  made  by  Meyer  J 

Although  clinically  this  condition  is  not  very  well  defined 
and  varies  a  good  deal  in  its  aspect,  the  anatomical  changes 
found  post  mortem  are  highly  characteristic  and  constitute 
the  basis  of  its  autonomy. 

These  changes  are  revealed  only  on  microscopic  exami- 
nation and  consist  in  widespread  parenchymatous  degen- 
eration of  the  central  nervous  system  unaccompanied  by  any 
inflammatory  reaction.  Large  nerve  cells,  especially  those 
in  the  motor  area  of  the  cortex  in  both  cerebral  hemispheres, 
present  the  so-called  axonal  alteration:  the  cell  body  is 
somewhat  swollen;  the  stainable  substance,  especially  in 
the  central  part  of  the  cell,  is  converted  into  a  diffusely 
staining,  structureless,  or  into  a  finely  powdered,  mass; 
the  nucleus  is  pushed  toward  the  periphery  of  the  cell  and 
may  be  slightly  flattened  or  distorted.  Marchi  preparations 
reveal  corresponding  degeneration  of  fiber  tracts,  particularly 
those  connected  with  the  motor  cortical  areas. 

The  nature  of  central  neuritis  is  not  understood,  and 
but  little  is  known  of  its  etiology.  Most  cases  that  have  been 
reported  occurred  in  institution  practice  either  as  terminal 

^  J.  Wiglesworth.  On  the  Pathology  of  Certain  Cases  of  Melancholia 
Attonita,  or  Acute  Dementia.     Journ.  of  Ment.  Sc,  Oct.,  1883. 

^  Adolf  Meyer.  Demonstrations  of  Various  Types  of  Changes  in 
the  Giant  Cells  of  the  Paracentral  Lobules.  Amer.  Journ.  of  Ins.,  Oct., 
1897. 

^  W.  L  Worcester.  A  Case  of  Landry's  Paralysis.  Journ.  of  Nerv. 
and  Ment.  Dis.,  1897. 

*  John  Turner.  Note  on  a  Form  of  Dementia  Associated  ivith  a 
Definite  Change  in  the  Appearance  of  the  Pyramidal  and  Giant-Cells 
of  the  Brain.     Brain,  1899. 

^  H.  A.  Cotton  and  E.  E.  Southard.  A  Case  of  Central  Neuritis 
vnth  Autopsy.     Trans,  of  the  Amer.  Med.-Psychol.  Assn.,  1908. 

^  E.  M.  Somers  and  C.  I.  Lambert.  Central  Neuritis.  State 
Hosp.  Bulletin,  December,  1908. 

^  Adolf  Meyer.  On  Parenchymatous  Systemic  Degenerations  Mainly 
in  the  Central  Nervous  System.     Brain,  1901. 


440 


MISCELLANEOUS  GROUPS 


".:-?■«'-.,    ' 


i'f    *,    . 


^,..,  ^«^.'  J*  / 

*--; 

'■^"V 

.     '.  >"      "S6 

''*.*--^^^Jfe^,  -^a^tj 

*-4 

Fig.  5.~ Normal  Betz  Cell.     (After  Adolf  Meyer.) 


Fig.  6. —  Cell  from  a  Case  of  Central  Nr^uritis,  showing  Axonal  Alter- 
ation.    (After  Adolf  Meyer.) 


ORGANIC  CEREBRAL  AFFECTIONS       441 

episodes  in  some  chronic  psychoses  or  in  connection  with 
acute  mental  confusion.  It  affects  both  sexes,  chiefiy  in  the 
fifth  and  sixth  decades  of  Hfe  or  thereabouts.  In  most  of  the 
cases  no  exciting  cause  is  assigned ;  in  a  considerable  number 
the  trouble  is  said  to  have  followed  an  attack  of  influenza, 
and  in  three  cases  it  followed  slight  surgical  operations 
done  under  general  anaesthesia. 

Singer  and  Pollock  ^  found  the  lesions  of  central  neuritis 
in  a  series  of  twelve  cases  of  pellagra  dying  during  the  acute 
or  subsiding  stages  of  the  pellagrous  attack.  "  Seven  of 
them  died  at  a  short  interval  after  the  skin  lesions  had  sub- 
sided, with  clinical  symptoms  of  central  neuritis.  In  the 
other  five  there  were  no  symptoms,  such  as  evidence  of 
pyramidal  tract  lesion  (Babinski  reflex,  jactatoid  spasms, 
etc.),  to  suggest  central  neuritis,  although  diarrhoea  with 
rapid  and  progressive  emaciation  and  weakness  were  almost 
always  present."  This,  of  course,  suggests  the  possibility 
of  an  essential  connection  between  central  neuritis  and  pella- 
gra which  had  been  previously  overlooked. 

The  mental  symptofns,  given  in  the  order  of  their  fre- 
quency, are:  depression  with  anxiety  or  sudden  apprehen- 
siveness;  restlessness  and  agitation;  perplexity,  confusion; 
hypochondriacal  or  persecutory  delusions,  often  of  an 
extremely  absurd  character;  hallucinations.  Refusal  of  food 
has  occurred  in  more  than  half  of  the  cases,  and  suicidal 
tendency  is  almost  as  common. 

Among  the  physical  symptoms  the  most  striking  are: 
stumbling,  falling,  unsteady  gait;  peculiar  seizures — faint- 
ness,  violent  shaking,  rigidity;  muscular  twitchings,  irregu- 
lar jerky  movements,  jactations;  maladjustment  in  all 
movements;  the  knee-jerks  are  most  frequently  exag- 
gerated, but  in  some  cases  they  are  diminished  or  even 
absent;  the  speech  is  apt  to  become  very  indistinct;  toward 
the  last,  dysphagia;  in  some  cases  there  is  little  or  no  reaction 
to   pin-pricks.     The   general   constitutional   disturbance   is 

1  Singer  and  Pollock.  The  Histopathology  of  the  Nervous  System 
in  Pellagra.     Archives  of  Internal  Medicine,  June,  1913. 


442  MISCELLANEOUS  GROUPS 

grave:  there  is  usually  emaciation  which  may  be  extreme; 
diarrhoea  has  been  observed  in  nearly  three-fourths  of  the 
cases;  a  shght,  irregular  febrile  reaction  appears,  the  patient 
becomes  exhausted,  falls  into  stupor,  and  dies;  in  some  cases 
death  follows  a  sudden  turn  for  the  worse  or  actual  collapse. 


CHAPTER  XXII 

MISCELLANEOUS  GROUPS  {Concluded) 

SENILE  DEMENTIA 

Senile  dementia  may  be  defined  as  a  peculiar  state  of 
mental  deterioration,  with  or  without  delusions,  resulting 
from  cerebral  lesions  determined  by  senility. 

Age  is  here,  therefore,  the  great  etiological  factor;  it  is, 
however,  not  the  sole  factor.  Many  attain  extreme  old  age 
without  presenting  any  appreciable  intellectual  disorders; 
others,  on  the  contrary,  have  scarcely  passed  over  the  thresh- 
old of  senility  when  they  are  already  veritable  dements.^ 
The  effects  of  age  are  the  more  powerful  and  the  more 
precocious  the  more  marked  the  predisposition.  Heredity, 
the  intoxications  (alcoholism),  overwork,  violent  and  pain- 
ful emotions,  traumatisms,  etc.,  are  also  given  as  causes. 

Statistics  furnish  a  rather  small  proportion  of  congeni- 
tally  predisposed  persons  among  senile  dements,  but  this  is 
perhaps  partly  due  to  the  fact  that  it  is  frequently  impossible 
to  obtain  reliable  family  histories  in  such  cases. 

Senile  dementia  is  rare  before  the  age  of  sixty  years. 
Alcoholism  sometimes  brings  about  an  analogous  state  of 
mental  deterioration,  appearing  toward  fifty  or  fifty-five 
years,  which  has  been  designated  by  the  term  scenia,n 
'prcEcox?  Such  cases  are  exceptional  if  we  exclude  ordinary 
alcoholic  dementia. 

1  Russell.  Senility  and  Senile  Dementia.  Amer.  Journ.  of  Insanity, 
1902. 

2  Cases  essentially  of  premature  senility  have  been  described  under 
the  name  of  Alzheimer's  disease.     See  Alzheimer,     Ueber  eigenartige 

443 


444  MISCELLANEOUS  GROUPS 

The  onset  sometimes  follows  some  strong  emotional 
shock,  financial  troubles,  or  a  somatic  affection.  Almost 
always  it  is  insidious,  marked  simply  by  a  change  of  dis- 
position and  slight  disorders  of  memory.  When  fully 
established  the  dementia  presents  the  following  fundamental 
elements : 

(a)  Impairment  of  attention  and  sluggishness  of  asso- 
ciation of  ideas,  readily  demonstrable  by  psychometry,  as 
has  been  shown  by  the  experiments  of  Rauschburg  and 
Balint.i  (These  authors  performed  their  experiments  upon 
cases  of  simple  senile  dementia  without  delusions.)  A  curious 
fact  observed  in  these  experiments  is  that  associations  of 
ideas  were  almost  always  determined  by  the  sense  of  the 
words,  and  rarely  by  similarities  of  sound  or  by  rhymes. 
It  will  be  remembered  that  associations  by  similarities  of 
sound  are  the  result  of  automatic  psychic  activity;  it  seems, 
therefore,  that  mental  automatism,  instead  of  being  exagger- 
ated, as  it  is  in  certain  psychoses  (mania),  is,  like  voluntary 
psychic  activity,  diminished,  at  least  in  simple  senile  dementia 
without  delusions. 

(h)  Inaccurate  and  incomplete  perception,  the  conse- 
quence of  which  is  the  production  of  mmierous  illusions 
and  of  disorientation  of  place. 

(c)  Disorders  of  memory,  comprising: 

(I)  Amnesia  of  fixation  (anterograde  amnesia),  which 
entails  disorientation  of  time; 

krankheitsfalle  des  spdteren  Alters.  Zeitschr.  f.  d.  gesamte  Neurol,  u. 
Psychiatrie,  Vol.  IV,  p.  365.— Perusini.  Ueber  klinisch  und  Mstologisch 
eigenartige  psychische  Erkrankungen  des  spateren  Lebensalters.  Nissl's 
Arbeiten,  Vol.  II,  p.  297.— S.  C.  Fuller.  A  Study  of  the  Miliary 
Plaques  Found  in  Brains  of  the  Aged.  Amer.  Journ.  of  Ins.,  Oct., 
1911. — S.  C.  Fuller.  Alzheimer's  Disease  {Senium  Prcecox):  The  Report 
of  a  Case  and  Review  of  all  Published  Cases.  Journ.  of  Nerv.  and  Ment. 
Dis.,  Vol.  XXXIX,  1912.— S.  C.  Fuller  and  H.  I.  Iflopp.  Further 
Observations  on  Alzheimer's  Disease.  Amer.  Journ.  of  Ins.,  July,  1912. 
— W.  J.  Tiffany.  The  Occurrence  of  Miliary  Plaques  in  Senile  Brains. 
Amer.  Journ.  of  Ins.,  Jan.,  1914. 

1  Ueber  qualitative  und  quantitative,  etc.  AUgem.  Zeitsch.  fiir 
Psychiat.,  1900. 


SENILE  DEMENTIA  445 

(II)  Amnesia  of  conservation  (retrograde  amnesia),  which 
is  progressive  and  which  follows  almost  perfectly  the  law  of 
retrogression ; 

(III)  Illusions  and  hallucinations  of  memory,  which  form 
the  basis  of  pseudo-reminiscences,  often  absurd  or  puerile 
in  character  and  varying  from  one  instant  to  another. 

(d)  Impoverishment  of  the  stock  of  ideas:  old  impressions 
disappear  and  are  not  replaced  by  new  ones.  This  is  the 
cause  of  the  tiresome  repetitions  in  the  discourses  of  old 
dotards. 

(e)  Loss  of  judgment:  the  patieht  does  not  accept  new 
points  of  view.  He  mourns  for  the  good  old  times  and  shows 
a  profound  contempt  for  new  ideas  which  he  is  incapable  of 
assimilating.  This  contempt  for  the  present  is  met  with 
in  many  old  people  and  not  necessarily  in  combination 
with  any  appreciable  mental  deterioration. 

The  senile  dement  has  no  realization  of  his  own  condi- 
tion. Often  he  boasts  of  his  endurance,  strong  will,  lucid 
mind,  and  declares  that  he  is  in  no  need  of  assistance  from 
anyone  and  is  quite  able  to  manage  his  own  affairs. 

(/)  Diminution  of  affectivity,  7norhid  irritability:  hence 
the  indifference  of  senile  dements  for  their  relatives  and  their 
interests,  their  unprovoked  outbursts  of  anger,  their  tyran- 
nical tendencies,  and  their  occasional  emotionalism. 

{g)  Automatic  character  of  reactions:  from  this  point  of 
view  senile  dements  may  be  divided  into  two  classes:  the 
turbulent  and  the  apathetic. 

The  turbulent  are  always  moving,  intrude  everywhere, 
give  unreasonable  or  contradictory  orders,  get  up  during 
the  night  and  wander  about  the  house  with  a  candle  in  their 
hand  at  the  risk  of  starting  a  fire.  Their  mood  is  either 
depressed  or  elated  and  hypomaniacal.  Sexual  excitement, 
most  often  purely  psychic,  is  quite  likely  to  be  associated 
with  this  state,  and,  together  with  the  mental  deterioration, 
leads  the  patient  to  dangerous  acts:  attempts  of  rape,  in- 
decent exposures,  etc. 

The  apathetic  senile  dements  have  an  indifferent,  stupid 


446  MISCELLANEOUS  GROUPS 

aspect.  The  patient's  mouth,  half  open,  allows  the  saliva 
to  dribble;  he  remains  riiotionless  upon  the  chair  where  he 
has  been  placed;  he  is  docile,  obedient,  and  very  suggest- 
ible. In  the  hands  of  unscrupulous  persons  he  allows  him- 
self without  protestation  to  be  swindled  and  maltreated, 
and  unconsciously  yields  to  inveiglements  for  imprudent 
disposal  of  his  property. 

In  advanced  stages  of  the  disease  turbulent  as  well  as 
apathetic  senile  dements  frequently  become  filthy,  often 
soiling  and  wetting  themselves. 

Sleep  is  diminished  and  often  even  absent  in  the  excited 
forms.  On  the  other  hand,  constant  somnolence  is  frequent 
in  the  apathetic  cases. 

Together  with  the  dementia  there  are  the  regular  signs 
of  senility.  The  skin  is  wrinkled  and  discolored;  the  hairy 
system  is  undergoing  atrophy;  the  patellar  reflexes  are 
sometimes  abolished,  but  more  frequently  exaggerated;  the 
pupils  are  slightly  myotic  and  paretic;  arcus  senilis  is  well 
marked;  there  is  hyposesthesia  of  all  the  senses;  all  move- 
ments are  awkward  and  uncertain;  there  is  diminution  of  the 
muscular  power;  senile  tremors  affect  the  entire  body  and 
especially  the  head,  consisting  of  coarse  oscillations. 

The  cardio-vascular  symptoms  are  of  great  importance. 

The  frequent  association  of  senile  dementia  with  arte- 
riosclerosis has  already  been  mentioned.  Vascular  disease 
is,  however,  not  invariably  present  and  is  often  but  slight: 
senile  atrophy  is  a  process  essentially  independent  of  arterio- 
sclerosis. 

The  appetite  is  diminished,  or,  on  the  contrary,  it  may 
be  exaggerated  to  a  degree  constituting  voracity.  In  the 
latter  case  the  patient's  diet  should  be  carefully  regulated  to 
prevent  grave  gastro-intestinal  disturbances. 

Delusional  Forms. — The  delusions  bear  the  stamp  of 
dementia:  they  are  absurd,  changeable,  and  present  little 
or  no  tendency  to  systematization.  They  may  be  of  the 
following  varieties : 

(a)  Ideas   of  persecution,   which  in  their  mildest  form 


SENILE  DEMENTIA  447 

manifest  themselves  by  mere  suspiciousness  such  as  is 
always  common  in  old  persons.  Their  form  is  varied: 
ideas  of  poisoning,  theft,  jealousy,  fear  of  being  killed,  etc. 

Persecutory  ideas  are  more  likely  to  become  system- 
atized than  any  others,  though  the  systematization  is  very 
imperfect;  and  more  likely  to  be  accompanied  by  halluci- 
nations, chiefly  of  hearing  and  vision.  Sometimes  these 
delusions  appear  long  before  any  evidences  of  dementia, 
constituting  the  presenile  paranoid  state  (Prceseniler  Beein- 
trdchtigungswahn)  of  Kraepelin. 

(6)  Melancholy  ideas  of  all  possible  types:  ideas  of  self- 
accusation,  of  ruin,  etc.     Ideas  of  negation  are  very  frequent. 

(c)  Ideas  of  grandeur,  which  are  at  times  absurd,  re- 
sembling those  of  general  paralytics. 

The  delusions  are  associated  with  a  corresponding  state 
of  the  emotions  and  of  the  reactions.  Three  principal  forms 
of  delusional  senile  dementia  may  be  distinguished: 

(1)  Persecutory  form:  ideas  of  persecution;  reactions  of 
self-defense  which  may  at  times  be  violent. 

(2)  Depressed  form:  melancholy  ideas,  psychic  pain, 
depression,  anxiety,  suicidal  ideas. 

(3)  Maniacal  form:  euphoria,  ideas  of  grandeur,  variable 
moods,  impulsive  reactions,  sometimes  flight  of  ideas, 
erotic  tendencies,  etc. 

Senile  dementia  is  sometimes  marked  by  acute  attacks 
characterized  by  complete  disorientation  and  hallucinations, 
closely  resembling  certain  phases  of  general  paralysis,  but 
especially  delirium  tremens  (senile  delirium) .  These  attacks, 
usually  very  brief,  terminate  either  in  death  or  in  a  return 
to  the  previous  condition.  They  may  occur  in  old  persons 
independently  of  senile  dementia  (Wernicke). 

The  principal  complications  of  senile  dementia  are: 

Apoplectic  and  sometimes  epileptic  seizures  (senile 
epilepsy),  hemiplegia,  aphasic  phenomena,  etc. 

Alcoholism  in  the  form  of  episodic  accidents  (delirium 
tremens)  or  of  alcoholic  dementia  may  be  associated  with 
senile  dementia. 


448  MISCELLANEOUS  GROUPS 

The  prognosis  is  fatal.  The  affection  always  follows  a 
progressive  course.  Remissions  are  very  rare  and  never 
complete.  Death  usually  supervenes  at  the  end  of  from 
three  to  five  years,  as  a  result  of  senile  cachexia,  some  inter- 
current disease  (pneumonia),  or  apoplexy. 

Not  all  psychoses  occurring  at  an  advanced  age  are 
senile  dementia.  Old  men  present  attacks  of  manic-depres- 
sive psychoses,  paranoia,  and  other  psychoses  which  differ 
in  no  way  from  those  observed  in  younger  people.^ 

The  diagnosis  is  based  upon  the  pathognomonic  features 
of  the  dementia. 

Involutional  melancholia  and  manic-depressive  psychoses 
may  be  distinguished  by  the  absence  of  mental  deterioration, 
by  the  preservation  of  lucidity,  and  by  the  intensity  of  the 
affective  phenomena — psychic  pain  or  euphoria. 

General  paralysis  may  be  differentiated  by  the  more 
rapid  development  of  dementia  and  by  its  special  physical 
signs. 

Alcoholic  dementia  shows  the  physical  signs  of  chronic 
alcoholism:  muscular  pain,  tremors,  gastric  disorders,  etc. 
Senile  dementia  and  alcoholic  dementia  may  exist  together. 

The  anatomical  lesions  arise  from  a  process  of  wear  and 
atrophy:  atheroma  of  the  cerebral  arteries,  thickening  of  the 
meninges,  diminution  of  the  weight  of  the  brain,  which  may 
sometimes  fall  below  1000  grams;  thinning  of  the  cortex; 
numerous  miliary  plaques;  diminution  of  the  number  of 
nerve-cells,  chromatolysis,  pigmentary  degeneration,  atrophy; 
disappearance  of  a  large  number  of  tangential  fibers. 

The  treatment,  purely  symptomatic,  consists  chiefly 
in  hygienic  measures.  Commitment  is  but  seldom  neces- 
sary. The  majority  of  cases  are  best  treated  in  special 
asylums  for  the  aged  or  in  private  homes. 

3  Thivet.  Contribution  a  V etude  de  la  folic  chez  les  vieillards.  These 
do  Paris,  1889. — Regis.  Psychoses  de  la  vieillesse.  Ann.  med.  psych., 
March-April,  1897. — Ritti.  Les  psychoses  de  la  vieillesse.  Congres 
des  m^decins  ali^nistes  et  neurologistes,  1896. 


PART  III 

APPENDICES    DEALING    WITH    TECHNIQUE    OF 
SPECIAL    DIAGNOSTIC    PROCEDURES 


APPENDIX  I 
LUMBAR  PUNCTURE— CELL  COUNT— CHEMICAL  TESTS 

Lumbar  puncture  is  a  simple  and  harmless  procedure. 
The  only  danger,  that  of  infection,  can  be  entirely  avoided 
by  the  exercise  of  ordinary  precautions  of  asepsis. 

The  only  contraindication  is  high  intracranial  pressure. 
Patients  who  have  brain  tumor  with  signs  of  increased 
intracranial  pressure,  especially  choked  disc,  should  be 
punctured  only  when  this  is  deemed  absolutely  necessary 
for  differential  diagnosis,  and  then  not  more  than  2  c.c.  of 
spinal  fluid  should  be  withdrawn.  Death,  caused  by  hernia 
of  the  medulla  and  midbrain  into  the  foramen  magnum,  has 
followed  withdrawal  of  large  amounts  of  fluid  in  such  cases. ^ 

The  patient  is  placed  on  a  convenient  table,  or  a  board 
is  inserted  under  the  mattress  of  his  bed.  He  lies  on  his 
side,  with  the  back  arched  as  much  as  possible  and  with 
knees  drawn  up  so  that  they  almost  touch  his  chin.  The 
patient  may  aid  this  arching  of  the  back  by  placing  his  hands 
behind  the  knees  and  exerting  a  strong  pull.  An  assistant 
can  keep  a  restless  patient  from  moving  by  placing  one 
hand  on  the  nape  of  his  neck  and  the  other  behind  the  knees 
and  thus  holding  him  firml5^  Very  restless  and  excited  pa- 
tients must  be  given  a  general  anaesthetic. 

1  Minet  and  Lavoit.  La  mort  suite  de  ponction  lambaire.  L'ficho 
medical  du  Xord,  Apr.  25,  1909. 

449 


450  CEREBRO-SPINAL  FLUID 

Two  conditions  are  essential:  the  back  must  not  be 
arched  in,  but  out,  and  the  ahgnment  of  the  vertebrae  must 
not  be  scoliotic,  but  straight.  The  back  is  then  sterilized  with 
some  tincture  of  iodine,  which  is  removed  with  a  little  alcohol. 
The  operator's  hands  are,  of  course,  also  properly  sterilized. 
To  mitigate  the  slight  pain  incident  to  piercing  the  skin, 
the  latter  may  be  anaesthetized  with  ethyl  chloride. 

A  lumbar  puncture  needle,  sterilized  in  an  oven  by  dry 
heat  at  150°  C.  for  half  an  hour,  is  used.  It  is  best  to  have 
several  such  needles  on  hand.  They  can  be  conveniently 
placed  in  cotton-stoppered  test-tubes,  and  if  the  oven  tem- 
perature cannot  be  accurately  observed  by  thermometer  it  is 
sufficient  to  roast  them  until  the  cotton  begins  to  turn  brown. 

This  method  of  sterilization  is  preferable  to  boiling  the 
needles,  as  it  is  desirable  to  have  them  quite  dry.  Globulin, 
the  detection  of  which  is  the  object  of  some  of  the  spinal 
fluid  tests,  is  precipitated  by  water.  Boiled  needles  may 
be  used,  however,  but  in  that  case  it  is  best  to  discard  the 
first  three  or  four  drops  of  spinal  fluid. 

The  needle  should  be  about  4|  inches  long  and  not  larger 
than  gauge  18  nor  smaller  than  gauge  22  of  the  Brown  & 
Sharpe  standard. 

The  needle  is  introduced  straight  into  the  space  between 
the  laminae  of  the  fourth  and  fifth  lumbar  vertebrae.  This 
interspace  is  found  by  drawing  an  imaginary  line  joining 
the  iliac  crests.  Should  this  interspace,  upon  palpation, 
prove  small  or  narrow,  the  one  above  or  the  one  below  may  be 
selected  instead.  The  needle  is  introduced  at  a  point  in  the 
midline  or  a  trifle  to  one  side,  just  below  the  tip  of  the  cor- 
responding vertebral  spine. 

Extending  from  the  level  of  the  upper  border  of  the  second 
lumbar  vertebra  to  that  of  the  sacrum  is  a  large  meningeal 
reservoir  in  which  are  contained  the  fibers  of  the  cauda 
equina.  These  fibers  are  loosely  held  in  place  and  are 
therefore  not  injured  by  the  point  of  the  needle.  Should 
the  needle  touch  them,  the  patient  is  apt  to  complain  of 
shooting  pains  and  cramps  in  the  legs.     This  is  no  reason 


LUMBAR  PUNCTURE  451 

for  interrupting  the  procedure.  The  pain  can  be  ehminated 
by  gently  rotating  the  needle  through  half  a  turn. 

If  in  the  process  of  introduction  it  is  felt  that  the  needle 
is  about  to  strike  bone,  no  attempt  should  be  made  to  push 
it  further,  for  then  the  very  sensitive  periosteum  would  be 
scraped.  The  operator  can  easily  tell  when  the  needle  is 
about  to  come  in  contact  with  bone,  as  the  resistance  of 
the  tendons  and  ligaments  near  the  vertebrae  is  greater 
than  that  of  the  more  superficial  tissues.  It  is  best  to 
withdraw  the  needle  entirely  and  to  try  again  with  another 
needle. 

In  some  cases  it  is  impossible  to  get  the  back  of  the  patient 
properly  arched  and  aligned.  Consequently  the  projecting 
spines  almost  obliterate  the  small  intervertebral  spaces. 
The  only  possibility  of  performing  lumbar  puncture  in  such 
a  case  is  by  directing  the  needle  at  an  angle  upward.  Every 
puncture  should  be  preceded  by  a  careful  palpation  of  the 
interspaces.  Thus  the  widest  interspace  may  be  selected  and 
the  operator  must  judge,  according  to  the  patient's  position, 
at  what  angle  to  introduce  the  needle.  The  direction  of  the 
needle  may  be  changed  only  after  withdra-v\ing  it  to  a  level 
just  under  the  skin,  otherwise  one  runs  the  risk  of  impacting 
it  and  breaking  it  off. 

A  decrease  in  resistance  gives  an  indication  when  the 
meningeal  reservoir  has  been  reached  and  when  the  stylet 
is  to  be  withdrawn  from  the  needle.  Often  the  dura  gives 
way  with  a  perceptible  pop.  A  mistake  often  made  is  to  push 
the  needle  too  far  into  the  spinal  canal;  thus  the  venous 
plexus  at  the  ventral  part  of  the  canal  is  injured  and  con- 
tamination of  the  fluid  with  blood  results.  Such  a  specimen 
can  be  used  only  for  the  Wassermann  reaction.  It  is  useless 
for  those  tests  which  presuppose  freedom  from  contamination 
with  such  blood  constituents  as  serum  albumin  and  globulin 
and  cellular  elements. 

Sometimes  the  needle  becomes  clogged  after  some  fluid 
has  been  collected.  In  such  cases  the  stylet  is  reinserted 
and  the  needle  is  turned  gently. 


452  CEREBRO-SPINAL  FLUID 

About  5  or  6  c.c.  of  the  fluid  are  collected  in  a  sterile 
test-tube.  It  is  not  advisable  to  withdraw  more  for  diagnostic 
purposes,  as  patients  are  apt  to  develop  severe  headache, 
faintness,  dizziness,  or  vomiting  if  too  much  fluid  is  with- 
drawn. Indeed,  headache  sometimes  follows  the  best  tech- 
nique and  greatest  care.  However,  it  seldom  lasts  over  a 
few  days. 

After  lumbar  puncture  the  patient  should  remain  in  bed 
for  at  least  twenty-four  hours.  Should  the  above-mentioned 
symptoms  appear  and  persist,  two  or  three  days'  rest  in  bed 
may  be  required. 

The  following  are  the  most  useful  procedures  for  ex- 
amining spinal  fluid  for  psychiatric  diagnosis :  (a)  Cell  count. 
(6)  Lange's  colloidal  gold  test,  (c)  Special  protein  tests 
(Noguchi,  Ross- Jones,  Pandy).  (d)  Wassermann  reaction 
(described  in  Appendix  II). 

(a)  The  cell  count  must  be  done  immediately  after  the 
fluid  has  been  collected,  as  the  cells  soon  undergo  autolytic 
action  outside  of  the  body. 

The  following  equipment  is  required:  (1)  Mixing  pipette 
like  that  used  for  making  white  blood-corpuscle  counts. 
(2)  Fuchs-Rosenthal  counting  chamber,  ruled  as  illustrated 
in  Fig.  7}  (3)  Clinical  microscope,  preferably  with  me- 
chanical stage.     (4)  The  following  staining  solution: 

Methyl-violet 0.2  gram 

Acetic  acid. 4.0  c.c. 

Distilled  water 96 . 0  c.c. 

Shake  well  and  filter  before  using. 

The  staining  solution  is  drawn  into  the  pipette  up  to 
mark  1,  and  then  the  spinal  fluid,  after  being  thoroughly 
shaken  to  insure  uniform  suspension  of  the  cells,  up  to  mark 
11;  the  pipette  is  then  shaken  for  about  five  minutes  to 
mix  the  stain  thoroughly  with  the  fluid. 

As  that  part  of  the  fluid  which  is  in  the  stem  of  the  pipette 
does  not  become  mixed  with  that  in  the  bulb,  and  is  drained 

^  Excellent  counting  chambers  of  American  manufacture  are  to  be 
had  from  Max  Levy,  Philadelphia. 


CELL  COUNT 


453 


off  before  a  drop  is  taken  out  for  the  counting  chamber, 
the  dilution  in  the  bulb,  in  calculating  the  results,  is  to  be 
considered  as  in  the  proportion  of  9  parts  of  spinal  fluid  to 
1  of  the  staining  solution. 

After  draining  off  the  fluid  in  the  stem  of  the  pipette — 
three  drops — a  drop  of  suitable  size  is  placed  in  the  counting 
chamber  and  a  cover  glass  put  on ;  or,  still  better,  if  one  of 
the  new  counting  chambers  of  American  manufacture  is 


Fig.  7. — Ruling  of  Fuchs-Rosenthal  Counting  Chamber. 

used,  a  drop  is  allowed  to  flow  in  by  capillary  attraction. 
It  is  best  to  let  the  fluid  stand  in  the  counting  chamber  about 
a  minute  before  the  counting  is  begun;  this  permits  the  cells 
to  settle  on  the  bottom  so  as  to  be  as  nearly  as  possible  in  the 
same  focus  as  the  ruling  of  the  chamber. 

The  count  is  made  most  conveniently  under  rather  low 
magnifying  power  of  the  microscope,  say,  16  mm.  objective, 
10  X  eye-piece,  Bausch  &  Lomb. 

The  dimensions  of  the  counting  chamber  are  4  mm.  on 


454  CEREBRO-SPINAL  FLUID 

each  side  and  0.2  mm.  in  depth,  i.e.,  3.2  cu.mm.  As  but 
nine-tenths  of  the  mixture  in  the  counting  chamber  is  spinal 
fluid,  the  remaining  one-tenth  being  staining  solution,  all  the 
cells  counted  in  one  chamber  represent  the  cell  content  of 
2.88  cu.mm.  of  spinal  fluid.  It  is  customary  to  express  the 
findings  in  number  of  cells  per  cubic  millimeter  of  spinal 
fluid;  and  this  is  derived,  of  course,  by  dividing  the  total 
number  of  cells  counted  over  the  entire  ruled  area  of  a  Fuchs- 
Rosenthal  chamber  by  2.88. 

It  is  advisable  to  make  two  or  three  counts  with  different 
drops  and  to  report  the  calculated  average  rather  than  the 
result  of  a  single  count. 

The  nijimber  of  cells  per  cu.mm.  of  spinal  fluid  varies 
considerably  both  in  health  and  disease,  and  there  is  no 
definite  point  of  demarcation  between  the  two.  Most  pathol- 
ogists consider  any  number  under  5  as  a  negative  finding, 
between  5  and  8  as  doubtful,  and  over  8  as  positive. 

The  staining  solution,  for  which  the  forniula  is  given 
above,  will  enable  one  to  differentiate  between  white  and  red 
corpuscles.  The  small  mononuclear  elements  assume  a  deep 
blue  color  with  a  narrow  lighter  rim  of  cytoplasm.  Red  cells 
appear  light  colored,  hyalin,  translucent.  Polymorphonu- 
clear elements  are  recognized  by  their  nuclei.  It  would  be 
easy  to  dissolve  all  red  cells  by  adding  more  acetic  acid 
to  the  staining  solution.  We  have  purposely  not  done  this, 
as  it  is  an  advantage  to  be  able  to  count  red  cells  as  well  as 
white  ones  and  thus  have  a  measure  of  the  contamination 
with  blood  that  there  might  be.  If  more  than  20  red  cells 
per  cu.mm.  are  found,  the  cell  count  as  well  as  the  colloidal 
gold  and  other  protein  tests  are  not  to  be  relied  on. 

In  cases  in  which  clinical  data  would  lead  the  physician 
to  expect  a  positive  finding,  while  the  reported  finding  is 
either  doubtful  or  negative,  the  lumbar  puncture  may  be 
repeated  at  the  end  of  ten  days.  Either  on  first  or  second 
examination  almost  all  cases  of  general  paralysis  and  cerebral 
syphilis  furnish  positive  findings,  while  most  other  psychoses 
furnish  negative  ones.  In  all  acute  infections  of  the  meninges 
polymorphonuclear  cells  are  found. 


CHEMICAL  TESTS  455 

(6)  Lange's  Colloidal  Gold  Test.^ — The  reagent  is  pre- 
pared as  follows:  One  uses  water  which  has  been  thrice  dis- 
tilled, and,  in  being  distilled,  has  not  been  allowed  to  come 
in  contact  with  rubber  connections,  all  connections  of  the 
distilling  apparatus  being  of  cork  which  has  been  well  boiled 
beforehand.  An  apparatus  hke  that  described  by  Miller, 
Brush,  Hammers,  and  Felton  ^  is  very  useful.  Three 
hundred  c.c.  of  such  thrice-distilled  water  is  put  into  a 
beaker  of  Pyrex  or  Jena  glass,  and  the  beaker  is  placed  on 
wire  gauze  over  a  hot  flame.  When  the  water  has  reached 
the  temperature  of  60°  C.  3  c.c.  of  a  1%  solution  of  gold 
chloride  in  similarly  thrice-distilled  water  is  added.  Follow- 
ing this  2.1  c.c.  of  a  2%  solution  of  pota/ssium  carbonate  of 
the  highest  purity  is  added.  The  solution  is  then  brought 
quickly  to  90°  C.  At  this  point  2.1  c.c.  of  a  1%  solution 
of  formaldehyde  is  added  gradually  while  stirring.  This  is 
prepared  by  diluting  1  c.c.  of  commercial  formaldehyde 
solution  (40%)  with  39  c.c.  of  thrice-distilled  water.  The 
whole  is  kept  at  a  temperature  of  90°  C.  until  a  pink  tinge 
appears ;  the  beaker  is  then  removed  from  the  flame  and  the 
reaction  allowed  to  complete  itself.  It  should  not  be 
allowed  to  boil  violently  at  any  time,  but  may  bubble  gently. 
The  solution  thus  prepared  should  be  perfectly  clear  and 
without  a  bluish  tinge.     It  will  keep  for  weeks  or  months. 

Before  using  the  solution  is  tested  as  follows:  5  c.c.  are 
put  into  each  of  three  small  test-tubes;  then  0.5  c.c.  of  a  1% 
sodium  chloride  solution  is  added,  to  the  first  tube,  1.0  c.c. 
to  the  second,  and  1.7  c.c.  to  the  third.  The  first  tube 
should  show  no  change  in  color  at  the  end  of  an  hour,  the 
second  should  assume  a  blue  tinge,  and  the  third  should  show 
complete  precipitation  with  colorless  supernatant  fluid. 

If  this  titration  is  satisfactory,  the  solution  is  further 

^  Carl  Lange.  Die  Ausflokkung  kolloidalen  Goldes  durch  Cerebro- 
spinalflussigkeit  bei  syphilitischen  Affectionen  des  Centralnervensy stems. 
Zeitschr.  f.  Chemotherapie,  No.  1,  1912. — Kaplan  and  McClelland. 
The  Precipitation  of  Colloidal  Gold.  Journ.  Amer.  Med.  Assn.,  Feb. 
14,  1914. 

2  Miller,  Brush,  Hammers,  and  Felton.  Bulletin  of  Johns  Hopkins 
Hospital,  Vol.  XXVI,  p.  391,  1915. 


456  CEREBRO-SPINAL  FLUID 

tested  with  a  specimen  of  spinal  fluid  known  to  have  given  a 
paretic  curve. 

If  the  above  titration  is  unsatisfactory,  it  is  advisable  to 
determine  the  reaction  of  the  solution  with  the  aid  of  alizarin 
red.  Both  alkalinity  and  acidity  interfere  with  the  reaction, 
the  one  retarding  and  the  .other  hastening  it.  If  found 
necessary,  therefore,  the  reagent  should  be  neutralized  with 
N/50  hydrochloric  acid  or  sodium  hydroxide,  as  the  case 
might  be,  using  alizarin  red  as  indicator.  It  is  then  again 
titrated  with  sodium  chloride  solution,  as  described  above. 
If  the  titration  is  still  unsatisfactory,  then  something  may  be 
judged  to  be  wrong  either  with  the  chemicals  used  or  with 
the  technique,  and  a  new  solution  has  to  be  made. 

The  only  other  solution  required  is  0.4%  sodium  chloride 
in  thrice-distilled  water. 

The  test  is  performed  in  the  following  way:  ten  small 
test-tubes  are  placed  in  a  rack;  one  puts  1.8  c.c.  of  the  0.4% 
sodium  chloride  solution  in  the  first  test-tube  in  the  rack 
and  1  c.c.  in  each  of  the  other  nine.  0.2  c.c.  of  the  spinal 
fluid  is  then  put  into  the  first  test-tube,  making  therein  a 
dilution  of  1  :  10;  from  this  1  c.c.  is  taken  out  and  put  into 
the  second  test-tube,  making  therein  a  dilution  of  1  :  20 ; 
this  is  repeated  until  the  entire  series  of  tubes  contain 
dilutions  of  the  spinal  fluid  of  descending  strengths,  that 
in  the  tenth  tube  being  a  dilution  of  1  :  5120.  In  order  to 
make  the  volume  of  the  mixture  in  the  tenth  tube  the  same 
as  in  the  other  tubes,  1  c.c.  is  taken  out  and  thrown  away. 
To  each  tube  is  now  added  5  c.c.  of  the  colloidal  gold  solu- 
tion, the  mixture  shaken  up,  and  the  rack  left  to  stand  at 
room  temperature  for  twenty-four  hours,  at  the  end  of  which 
time  the  reading  is  taken. 

In  recording  the  reading  it  is  customary  to  distinguish  five 
degrees  of  intensity  of  reaction :  a  negative  reaction  leaves 
the  fluid  in  the  test-tube  salamander  red  in  color,  as  in  the 
beginning,  and  is  designated  0;  a  slightly  positive  reaction 
is  indicated  by  a  reddish-blue  color,  and  is  designated  1; 
a  somewhat  more  strongly  positive  reaction  renders  the  fluid 


CHEMICAL  TESTS 


457 


purple,  and  is  designated  2;  the  next  intensity  of  reaction 
is  indicated  by  a  blue  color,  and  is  designated  3;  the  next 
again  by  a  pale  blue  color,  and  is  designated  4;  and  the 
strongest  intensity  of  reaction,  marked  by  complete  precipi- 
tation, is  indicated  by  a  colorless  condition  of  the  super- 
natant fluid,  and  is  designated  5. 

The  colloidal  gold  test  is  essentially  a  measure  of  the  re- 
lationship between  the  globulins  and  albumins  in  the  spinal 
fluid.^  Fluids  with  a  large  globulin  content  and  little 
or  no  albumin  give  paretic  curves,  like  the  general  type  shown 


Intensity  of 

Spinal  Fluid  Dilution,  1  part  in 

Reaction. 

10 

20 

40 

80 

160 

320 

640 

1280 

2560 

5120 

6 

Colorless 

4 

Pale  blue 

\ 

\ 

3 

Blue 

\ 

\ 

2 

Purple 

^ 

\ 

1 

Reddish  blue 

\ 

0 

Salamander  red 

0 

Fig.  8.— Collodial  Gold  Test:  Paretic  Curve. 


in  Fig.  8.  This  curve,  expressed  in  numerals,  would  read: 
5555543200.  Such  curves  are  most  frequently  obtained 
in  cases  of  general  paralysis.  Some  other  conditions, 
notably  multiple  sclerosis  and  lead  poisoning  with  brain 
involvement,  sometimes  furnish  similar  curves. 

Fluids  with  limited  globulin  and  moderate  albumin  con- 
tent give  luetic  curves,  like  the  general  type  shown  in  Fig.  9. 
This  curve,  expressed  in  numerals,  would  read:  1133100000. 
It  is  most  frequently  found  in  tabes  and  endarteritic  and  gum- 
matous forms  of  cerebro-spinal  syphilis.     It  may  also  be 

1  Felton.  A  Study  of  the  Specificity  of  the  Colloidal  Gold  Reaction 
from  the  Physico-Chemical  Standpoint.     Journ.  Amer.  Med.  Assn.,  1917. 


458 


CEREBRO-SPINAL  FLUID 


found   in   cases   of   brain   tumor,    cerebral   arteriosclerosis, 
poliomyelitis,  etc. 


Intensity  of 

Spinal  Eluid  Dilution,  1  part  in 

Reaction. 

10 

20 

40 

80 

160 

320 

640 

i-^so 

2560 

5120 

5 

Colorless 

4 

Pale  blue 

8 

Blue 

2 

Purple 

/ 

\ 

1 

Reddish  blue 

/ 

V 

0 

Salamander  red 

' 

\ 

:^ 

Fig.  9.— Colloidal  Gold  Test:  Luetic  Curve. 

Fluids  containing  large  amounts  of  both  globulin  and 
albumin  give  meningitic  curves,  like  the  general  type  shown 
in  Fig.  10.  This  curve  expressed  in  numerals,  would  read: 
1234553100.  It  is  the  least  helpful  of  all  curves  as  far  as 
definite  diagnosis  is  concerned.  All  meningitic  conditions, 
be  they  of  syphilitic,  tubercular,  or  acute  infectious  nature, 
show  curves  of  this  general  type. 


Intensity  of 

Spinal  Fluid  Dilution,  1  part  in 

Reaction. 

10 

20 

40 

80 

160 

320 

640 

1280 

2560 

5120 

K 

Colorless 

4 

Pale  blue 

/ 

/ 

\ 

3 

Blue 

/ 

/ 

\ 

2 

Purple 

/ 

/ 

\ 

1 

Reddish  blue 

/ 

/ 

V 

0 

Salamander  red 

\ 

v^ 

Fig.  10.— Colloidal  Gold  Test:  Meningtic  Curve. 


CHEMICAL  TESTS  459 

(c)  Special  Protein  Tests. — Noguchi's  Butyric  Acid  Test} 
— To  0.2  c.c.  of  cerebro-spinal  fluid  in  a  small  test-tube  is 
added  0.5  c.c.  of  an  aqueous  solution  containing  10%  of  bu- 
tyric acid  and  0.9%  of  sodium  chloride,  and  the  mixture  is 
heated  over  a  flame  until  it  boils;  while  it  is  still  hot  0.1  c.c. 
of  a  4%  solution  of  sodium  hydroxide  is  added  and  the 
mixture  is  boiled  again.  A  positive  result  is  indicated  by  the 
appearance  at  once  or  after  a  few  minutes  of  a  finely  granular 
or  flocculent  precipitate  which  settles  in  a  little  while,  the 
supernatant  fluid  remaining  clear.  If  no  precipitate  forms 
or  if  only  a  diffuse  opalescence  develops  which  does  not  sub- 
side on  standing,  the  reaction  is  recorded  as  negative. 

Ross-Jones  Ammonium  Sulphate  Test? — Upon  2  c.c.  of  a 
hot  saturated  solution  of  ammonium  sulphate,  which  has  been 
allowed  to  cool  in  the  test-tube,  1  c.c.  of  cerebro-spinal 
fluid  is  allowed  to  flow  gently  from  a  pipette  in  such  a  manner 
that  it  will  form  a  layer  floating  on  top.  The  reaction  is  posi- 
tive if  within  a  few  minutes  a  thin  grayish  ring  is  formed 
at  the  junction  of  the  two  liquids.  After  standing  the  ring 
becomes  thicker  and  on  close  examination  in  a  suitable  light 
against  a  dark  background  may  be  seen  to  be  made  up  of  a 
fine  network  of  cobweb-like  appearance. 

Pandy's  Phenol  Test? — The  reagent  is  prepared  as  follows : 
Eighty  c.c.  of  pure  carbolic  acid  are  dissolved  in  1000  c.c. 
of  distilled  water.  This  mixture  is  well  shaken  and  allowed 
to  stand  several  days  at  room  temperature.  The  supernatant 
clear  solution  is  then  pipetted  off.  About  3  c.c.  of  this 
solution  is  poured  into  a  small  test-tube  and  three  drops  of 
spinal  fluid  are  added.  The  spinal  fluid,  which  is  of  higher 
specific  gravity  than  the  reagent,  falls  to  the  bottom.  A 
positive  reaction  is  indicated  by  a  distinct  streak  of  cloudi- 
ness in  the  course  of  the  spinal  fluid  through  the  reagent. 

1  Noguchi  and  Moore.  Journ.  Exp.  Med.,  1909,  p.  604.— Rosanoff 
and  Wiseman.  Syphilis  and  Insanity.  Amer.  Journ.  of  Insanity, 
Vol.  LXVI,  1910,  p.  419. 

2  British  Med.  Journ.,  1909,  Vol.  I,  p.  1111. 

^  D.  Kaplan.  Serology  of  Nerwus  and  Mental  Diseases:  Phila- 
delphia, 1914. 


APPENDIX  II 

WASSERMANN  REACTION 

Principle  of  the  Wassermann  Reaction. — When  blood 
corpuscles  of  an  animal  of  a  given  species  are  injected  into 
an  animal  of  a  foreign  species  the  blood  sermn  of  the  second 
animal  develops  the  power  of  destroying  the  corpuscles  of 
animals  of  the  first  species,  that  is  to  say,  a  specific  hmmolytic 
'power. 

When  the  serum  of  an  animal  thus  immunized  is  heated 
for  an  hour  at  56°  C,  or  when  it  has  been  allowed  to  stand 
at  room  temperature  for  twenty-four  hours,  it  loses  its  hsemo- 
lytic  power,  technically  it  is  said  to  have  become  inactivated. 
It  may,  however,  be  reactivated,  that  is  to  say,  its  hsemolytic 
power  may  be  restored,  by  the  addition  of  serum  from 
another  animal, — one  which  has  not  been  immunized  and 
the  serum  from  which,  therefore,  does  not  by  itself  possess 
hsemolytic  power. 

It  is  concluded  from  these  facts  that  the  hsemolytic 
power  of  the  serum  of  an  immunized  animal  is  dependent 
upon  two  substances:  one  which  is  chemically  unstable 
(being  easily  destroyed  by  moderate  heat  or  by  standing 
at  room  temperature)  and  non-specific  (being  present  in 
fresh  serum  of  non-immunized  animals  as  shown  by  reacti- 
vation), and  another  which  is  chemically  stable  (resisting 
the  effect  of  moderate  heating,  etc.)  and  strictly  specific 
(being  present  only  in  the  serum  of  animals  which  have  been 
immunized  by  injections  of  corpuscles).  The  first  sub- 
stance is  called  complement,  the  second  amboceptor. 

For  specific  haemolysis  to  occur,  then,  the  following 
ingredients  are  required,  constituting  a  hcemolytic  system: 

blood  corpuscles + complement + hsemolytic  amboceptor, 
460 


PRINCIPLE  461 

In  the  case  of  bacteria  the  mechanism  of  immuniza- 
tion is  similar;  accordingly,  the  essential  ingredients  in  a 
reaction  of  specific  bacteriolysis,  constituting  a  hacteriolytic 
system,  are: 

bacteria + complement +bacteriolytic  amboceptor. 

It  was  shown  by  Bordet  and  Gengou  that  in  any  bacteri- 
olytic reaction  a  definite  proportion  of  complement  is  used 
up,  and  that  the  amount  of  complement  thus  "  absorbed  " 
or  "  fixed  "  may  be  used  as  a  measure  of  the  immunity 
reaction.  So  that  if  upon  mixing  in  a  test-tube  suspension  of 
bacteria,  complement,  and  bacteriolytic  amboceptor  we 
wish  to  determine  whether  bacteriolysis  has  taken  place,  we 
may  do  so  simply  by  testing  for  the  presence  of  complement; 
its  absence  would  prove  that  it  has  been  used  up  and  that 
the  immunity  reaction  has  taken  place,  while  its  presence 
would  prove  that  such  reaction  has  not  taken  place. 

The  test  for  complement  is  done  simply  by  adding  blood 
corpuscles  and  hsemolytic  amboceptor;  in  the  presence  of 
complement  haemolysis  will  occur,  in  its  absence  it  will, 
of  course,  not  occur. 

The  application  of  the  phenomenon  of  fixation  of  com- 
plement with  resulting  inhibition  of  haemolysis,  known  as  the 
Bordet-Gengou  phenomenon,  in  a  test  for  syphilis  is  due  to 
Wassermann. 

In  the  case  of  syphihs  the  ingredients  of  the  immunity 
reaction  are: 

syphilitic  antigen  i+ complement +sj'pliilitic  amboceptor. 

^  Antigen  is  a  general  term  applied  to  all  bodies,  such  as  bacteria, 
blood  corpuscles,  etc.,  which  are  capable  to  exciting  the  generation 
of  specific  antibodies.  The  Treponema  pallidum  not  having  at  that 
time  been  successfully  cultivated  on  artificial  media,  Wassermann 
employed  as  syphilitic  antigen  watery  extract  of  livers  from  congen- 
itally  syphilitic  infants.  It  has  since  been  found  that  certain  Upoid 
substances  which  may  be  extracted  from  normal  body  tissues,  curiously 
enough,  possess  in  a  greater  degree  than  true  syphilitic  antigen,  the 
property  of  binding  complement.  Such  lipoids  are  now  exclusively 
employed  as  antigen  in  the  reaction.     It  is  to  be  judged  from  this  that 


462  WASSERMANN  REACTION 

The  actual  test  is  performed  in  two  stages.  In  the  first 
stage  syphilitic  antigen,  complement,  and  the  serum  to  be 
tested  are  brought  together;  if  the  serum  contains  syphilitic 
amboceptor  the  reaction  will  take  place  and  complement 
will,  consequently,  be  used  up;  if  the  serum  does  not  contain 
syphilitic  amboceptor  the  reaction  will  not  take  place  and 
complement  will  therefore  remain  free.  The  second  stage 
of  the  reaction  consists  simply  in  the  addition  of  blood  cor- 
puscles and  hsemolytic  amboceptor  to  test  for  complement; 
in  the  case  of  a  syphilitic  serum,  complement,  having  been 
used  up  in  the  first  stage  of  the  reaction,  will  not  be  avail- 
able for  the  hsemolytic  system  and  there  will  be  no  haemol- 
ysis; in  the  case  of  a  non-syphilitic  serum,  complement  will 
remain  free  after  the  first  stage  of  the  test;  it  will  therefore 
be  available  for  the  hsemolytic  system,  and  hsemolysis  will 
take  place. 

Preparation  of  Reagents. — Complement  is  derived  from 
fresh  guinea-pig  serum,  the  following  being  the  most  con- 
venient way.  A  full-grown  guinea  pig  is  held  by  an  assistant 
over  a  large  Petri  dish  in  a  hyperextended  position  by 
grasping  the  head  with  one  hand  and  all  the  four  legs  with 
the  other.  A  long  slender  sharp  knife  is  introduced  into  the 
neck  at  the  side  just  in  front  of  the  vertebral  column  until  it  is 
thrust  through  on  the  other  side,  when  the  edge  of  the  blade 
is  turned  ventrally  and  all  the  tissues  in  the  front  part  of 
the  neck  are  cut  through.  The  blood  is  caught  in  the  Petri 
dish,  which  is  then  covered  and  set  aside  in  a  corner  out  of 
direct  sunlight  and  allowed  to  stand  at  room  temperature  for 
about  two  hours,  at  the  end  of  which  time  the  serum  may  be 
poured  off  and  used ;  or  the  Petri  dish  may  at  the  end  of  two 
hours  be  placed  in  the  refrigerator  where  it  may  be  kept  over- 
night and  used  on  the  following  morning;  but  standing  over- 
night at  room  temperature  renders  the  serum  inactive. 
If  kept  on  ice  the  activity  of  the  serum  is  reduced  much  more 

the  Wassermann  reaction  is  not  really  an  instance  of  the  Bordet- 
Gengou  phenomenon,  but  a  purely  empirical  and  unexplained  test  for 
syphiUs  which,  moreover,  is  not  strictly  specific. 


PREPARATION  OF  REAGENTS         463 

slowly,  so  that  it  usually  remains  good  for  about  forty-eight 
hours. 

In  performing  the  test  0.1  c.c.  of  this  serum  is  used. 
Guinea-pig  serum  is  very  rich  in  complement,  so  that  the 
amount  used  in  the  test  is  really  in  excess  of  that  actually 
required  for  complete  hsemolysis. 

It  is  customary  to  use  sheep  corpuscles  in  the  hsemolytic 
system.  The  blood  of  a  freshly  slaughtered  sheep  is  col- 
lected in  a  sterile  vessel,  defibrinated,  centrifuged,  and  the 
corpuscles  washed  at  least  five  times  with  0.9%  sodium 
chloride  solution  in  distilled  water,  by  pouring  off  the  super- 
natant serum  or  salt  solution,  adding  fresh  salt  solution, 
shaking  the  centrifuge  tube,  and  centrifuging  again.  The 
washed  sheep  corpuscles  are  used  in  immunizing  rabbits  for 
the  preparation  of  anti-sheep  amboceptor;  for  this  purpose 
one  adds  to  the  corpuscles  in  the  sedimentation  tube  only 
about  as  much  salt  solution  as  would  suffice  to  bring  the  cor- 
puscle suspension  to  the  original  concentration  of  the  blood, 
i.e.,  two  parts  by  volume  of  the  corpuscles  in  the  sedimenta- 
tion tube  to  one  part  of  salt  solution.  The  sheep  corpuscles 
are  also  used  as  a  reagent  in  the  reaction ;  for  this  purpose  a 
weaker  suspension  is  prepared  containing  but  five  parts  by 
volume  to  ninety-five  of  salt  solution. 

Anti-sheep  hcemolytic  amboceptor  is  derived  from  the 
blood  serum  of  a  rabbit  which  has  been  immunized  by  two 
injections  of  5  and  8  c.c.  of  sheep  corpuscles  respectively, 
in  the  above-mentioned  concentration,  at  an  interval  of  five 
days.  A  full-grown  male  rabbit  weighing  about  5  pounds 
is  preferred,  and  the  injections  are  made  into  the  ear  vein 
with  a  10-c.c.  syringe.  To  facilitate  the  injections  the  assist- 
ant holding  the  rabbit  places  his  thumb  at  the  root  of  the 
ear,  thus  impeding  the  blood  return  and  rendering  the  vein 
prominent.  A  needle  about  2  inches  long,  gauge  20,  is  used. 
Subcutaneous  injection  is  useless  and  may  simply  result  in 
a  slough;  therefore,  if,  as  the  injection  is  begun,  a  swelling 
forms,  the  needle  must  be  either  readjusted  or  reinserted 
until  proper  penetration  into  the  vein  is  assured.     On  the 


464  WASSERMANN  REACTION 

ninth  day  after  the  second  injection  a  small  amount  of 
blood  is  withdrawn,  centrifuged,  and  the  serum  tested 
for  hsemolytic  power.  If  a  dilution  of  1  :  1500  is  capable 
of  hsemolyzing  with  the  aid  of  guinea-pig  complement  a 
5%  suspension  of  sheep  corpuscles  in  about  half  an  hour, 
then  the  rabbit  is  ready  for  bleeding.  If  not,  it  may  be 
necessary  to  give  a  third  injection  of  sheep  corpuscles  and 
again  wait  eight  or  nine  days.  When  this  preliminary 
test  gives  a  satisfactory  result,  the  rabbit  is  exsanguinated, 
the  blood  being  collected  in  a  sterile  bowl,  covered,  and 
allowed  to  stand  at  room  temperature  for  twelve  or  sixteen 
hours.  The  serum  is  then  distributed  in  small  sterile  test- 
tubes,  putting  about  2  c.c.  in  each  and  adding  salt  solution 
containing  tricresol  in  small  amount  so  that  the  concentra- 
tion of  the  latter  does  not  exceed  1  :  2000.  The  tops  of  the 
tubes  are  sealed  with  a  blow-pipe  and  they  are  placed  on 
ice.  In  this  way  the  amboceptor  serum  may  be  preserved 
for  three  or  four  months. 

Kaplan  has  pointed  out  that  the  preliminary  standard- 
ization of  the  amboceptor  serum  does  not  sufl&ce  to  gauge  its 
hsemolytic  power  under  the  conditions  of  the  Wassermann 
reaction,  owing  to  the  slight,  but  appreciable,  non-specific 
inhibiting  power  of  normal  blood  serum  and  of  whatever 
antigen  may  be  used.  It  will,  therefore,  tend  to  eliminate 
error  if,  on  each  day  when  the  examination  of  a  series  of 
specimens  is  undertaken,  the  amboceptor  serum  is  stand- 
ardized anew  in  the  presence  of  a  non-syphilitic  serum  and 
the  usual  amount  of  antigen.  This  has  the  further  ad- 
vantage of  making  possible  the  allowance  for  any  change 
that  may  have  taken  place  in  the  strength  either  of  the 
amboceptor  or  of  the  antigen. 

The  standardization  is  carried  out  as  follows.  Six  test- 
tubes  about  10  cm.  long  and  1  cm.  in  diameter  are  placed  in  a 
rack,  and  into  each  are  put  0.2  c.c.  non-syphilitic  serum,  the 
usual  quantity  of  antigen,  0.1  c.c.  complement,  and  1.0  c.c. 
5%  sheep  corpuscle  suspension;  the  rack  is  then  placed  in 
the  incubator  for  one  hour,  at  the  end  of  which  time  the 


PREPARATION  OF  REAGENTS  465 

amboceptor  serum  is  added  in  amounts  varying  from  a  con- 
centration of  1  :  200  to  one  of  1  :  6400,  as  shown  in  the 
following  sample  titration;  the  rack  is  returned  to  the  incu- 
bator and  the  reading  taken  at  the  end  of  two  hours. 


TABLE 

15 

Amboceptor  serum 

200... 

Complete  ha3molysis 

400... 

i  I           i  I 

800... 

It                   K 

1600... 

tl                    t  C 

3200... 

Slight  inhibition. 

6400... 

Marked     " 

The  rule  for  actual  work  is  to  use  double  the  amount  of 
amboceptor  which  is  sufficient  to  give  complete  haemolysis 
under  conditions  such  as  those  of  the  above  titration.  Ac- 
cordingly one  would  select  in  this  case  an  amount  of  am- 
boceptor serum  to  give  a  concentration  of  1  :  800  or  1  :  1000. 

Antigen  may  be  prepared  in  many  different  ways,  and  it 
is  immaterial  which  of  these  is  chosen,  the  serviceableness 
of  the  product  depending  not  so  much  on  the  method  of 
preparation  as  on  the  care  and  results  of  its  standardization. 
The  method  that  seems  capable  of  yielding  a  most  uniform 
product  is  that  of  Noguchi:  thoroughly  mashed  beef  liver 
or  kidney  is  steeped  in  ten  times  its  volimie  of  absolute 
alcohol  in  the  incubator  for  seven  days,  at  the  end  of  which 
time  it  is  filtered  and  the  filtrate  evaporated  with  the  aid  of 
an  electric  fan  to  the  consistency  of  a  thick,  sticky  mass; 
this  mass  is  dissolved  in  a  small  quantity  of  ether,  the  solu- 
tion is  filtered,  and  to  the  filtrate  is  added  five  times  its 
volume  of  acetone;  the  precipitate  which  is  thrown  down 
immediately  is  allowed  to  settle  and  is  taken  up  after  the 
supernatant  fluid  has  been  decanted.  0.2  gram  of  this 
precipitate  is  dissolved  in  5  c.c.  of  ether  and  to  this  100  c.c. 
oi  0.9%  salt  solution  is  gradually  added;  the  resulting 
emulsion  is  filtered  through  paper  to  remove  flocculi  or  solid 
particles.  This  emulsion  can  be  kept  on  ice  for  weeks  with- 
out deteriorating,  and  the  stock  mass  of  antigen  can  be  kept 
even  for  months  under  acetone  also  on  ice. 


466 


WASSERMANN  REACTION 


Antigen  thus  prepared  possesses,  on  the  one  hand, 
true  antigenic  power,  that  is  to  say,  the  power  of  binding 
complement  in  the  presence  of  a  syphiUtic  serum  and  thus 
inhibiting  haemolysis,  and,  on  the  other  hand,  generally 
in  a  lesser  degree,  an  ■  anti-com'plementary  power,  that  is  to 
say,  a  power  of  destroying  complement  and  thus  inhibiting 
haemolysis  without  the  intervention  of  a  syphilitic  seriun. 
It  must  therefore  be  standardized  with  a  view  to  determin- 
ing the  proper  dosage  to  be  used  in  the  work  to  insure  ample 
antigenic  action  and  to  exclude  simple  anti-complementary 
action.  For  this  purpose  a  titration  is  carried  out  in  the  fol- 
lowing manner:  twenty  small  test-tubes  are  arranged  in 
two  rows  in  a  suitable  rack;  one  puts  into  each  test-tube 
1  c.c.  of  sheep  corpuscle  suspension  and  0.1  c.c.  of  com- 
plement, prepared  as  described  above;  to  each  of  the  tubes 
in  the  front  row  one  adds  also  0.2  c.c.  of  serum  from  a  syphi- 
litic subject,  known  to  give  a  positive  reaction;  one  adds 
finally  to  the  test  tubes  in  both  rows  the  antigen  emulsion 
in  amounts  varying  from  0.03  c.c.  in  the  first  test-tube  to 
1.0  c.c.  in  the  tenth,  as  shown  in  the  following  sample  titra- 
tion.    The  rack  is  then  placed  in  the  incubator  for  one  hour, 

TABLE  16 


Amount  of 

Antigen 

Emulsion. 

Front  row  of  tubes: 

Back  row  of  tubes:  in- 

inhibition of  haemolysis 

hibition  of  hajmolysis 

due  to  true  antigenic 

due  to  simple  anti- 

action. 

complementary  action. 

0.03  c.c. 

Complete  haemolysis 

Complete  haemolysis 

0.05  c.c. 

<  (           (1 

1 1           it 

0.07  c.c. 

Partial  inhibition 

It           It 

0.10  c.c. 

Complete  inhibition 

it           It 

0.12  c.c. 

i  i           it 

It           II 

0.20  c.c. 

11           It 

It           It 

0.25  c.c. 

1 1           1 1 

It           It 

0.50  c.c. 

tt           tt 

Partial  inhibition 

0.75  c.c. 

1 1           1 1 

Complete  inhibition 

1.00  c.c. 

1 1           II 

( (           ( ( 

COLLECTION  OF  SPECIMENS  467 

at  the  end  of  which  time  two  units  of  amboceptor  serum  are 
added  to  each  tube  in  both  rows  and  the  rack  is  again  placed 
in  the  incubator;  at  the  end  of  two  hours  of  the  second 
incubation  the  reading  is  taken. 

The  proper  dosage  of  a  specimen  of  antigen  giving  on  titra- 
tion results  like  those  represented  above  would  be  0.12  c.c. 

It  happens  sometimes  that  a  specimen  of  antigen  is  found 
on  titration  to  possess  either  too  feeble  an  antigenic  power 
or  too  strong  an  anti-complementary  power;  in  either 
case  it  cannot  be  used  and  another  lot  must  be  prepared. 

Collection  of  Specimens  for  Examination. — The  only- 
equipment  required  for  obtaining  a  blood  specimen  is  a  test- 
tube,  hollow  needle  about  1|  inches  long,  gauge  19,  with  a 
short  piece  of  rubber  tubing  attached  to  it,  and  a  tourniquet 
consisting  simply  of  a  piece  of  rubber  tubing  about  16  inches 
long.  The  tourniquet  is  applied  well  up  on  the  arm  tightly 
enough  to  impede  the  venous  but  not  the  arterial  flow; 
it  is  more  convenient  to  take  the  blood  from  the  left  arm. 
Having  selected  the  largest  sized  superficial  vein  just  above 
the  bend  of  the  elbow,  the  thumb  of  the  left  hand  is  placed 
on  the  vein  partly  to  fix  it  and  prevent  its  slipping  and  partly 
to  guide  the  point  of  the  needle ;  the  needle  then,  held  in  the 
right  hand  with  the  rubber  tube  projecting  into  the  test-tube 
which  is  also  held  in  the  right  hand  being  grasped  with  the 
little  and  ring  fingers,  is  thrust  into  the  vein  at  a  point  as 
close  as  possible  to  where  it  is  held  by  the  thumb  of  the  left 
hand ;  in  doing  so  the  needle  is  held  with  the  bevel  of  its  point 
upwards;  the  direction  of  the  thrust  is  inwards  and  upwards 
in  the  direction  of  the  vein.  If  the  vein  has  been  properly 
penetrated  blood  will  begin  to  trickle  into  the  test-tube  either 
immediately  or  in  a  second  or  two.  If  it  seems  that  the 
needle  has  pierced  through  the  vein  instead  of  into  it, 
blood  may  be  started  through  it  by  withdrawing  it  slightly. 
About  6  or  7  c.c.  of  blood  is  allowed  to  flow  into  the  test- 
tube,  the  needle  withdrawn,  and  the  puncture  protected 
with  a  piece  of  sterile  gauze  fastened  on  with  a  strip  of 
adhesive  plaster.     It  goes  without  saying  that  the  needle, 


468  WASSERMANN  REACTION 

test-tube,  etc.,  are  sterilized  before  being  used  and  that  the 
physician's  hands  and  the  patient's  arm  around  the  site  of 
the  puncture  are  scrubbed  properly. 

The  test-tube  containing  the  blood  is  stopped  with  a  cot- 
ton plug  and  allowed  to  stand  at  room  temperature  for  several 
hours,  at  the  end  of  which  time  the  serum  may  be  examined 
for  the  reaction  or  it  may  be  placed  in  the  refrigerator  to  be 
examined  on  the  following  day. 

Specimens  of  cerebro-spinal  fluid  are  obtained  by  lum- 
bar puncture,  the  technique  of  which  has  already  been 
described. 

Both  the  blood  serum  and  the  cerebro-spinal  fluid 
should  be  examined  if  possible  either  on  the  same  or  on  the 
following  day  after  they  have  been  obtained,  as  even  if 
kept  on  ice  they  soon  begin  to  undergo  changes  consisting 
most  commonly  of  a  development  of  non-specific  anti- 
complementary power. 

Technique  of  the  Reaction. — A  whole  rackful  of  specimens 
may  be  examined  together.  It  is  most  convenient  to  use  a 
test-tube  rack  with  spaces  for  two  rows  of  test-tubes.  Tubes 
10  cm.  long  and  1  cm.  in  diameter  are  best  for  the  purpose. 
For  testing  each  specimen  two  tubes  are  used,  a  front  tube  for 
the  reaction  and  a  rear  tube  for  control. 

All  the  blood  specimens  to  be  examined  are  first  inacti- 
vated by  being  placed  for  three-quarters  of  an  hour  in  a 
thermostat  at  a  temperature  not  exceeding  56°  C.  Spinal 
fluids  do  not  require  to  be  inactivated. 

0.2  c.c.  of  the  serum  or  spinal  fluid  to  be  examined  is  put 
in  a  front  tube  and  the  same  amount  in  a  corresponding  rear 
tube.  At  the  end  of  the  rack  two  pairs  of  tubes  are  reserved 
respectively  for  the  positive  and  negative  controls:  in  the 
positive  control  tubes  serum  or  cerebro-spinal  fluid  known 
to  give  a  positive  reaction  is  used;  in  the  negative  control 
tubes  neither  serum  nor  spinal  fluid  is  used.  To  each  tube 
is  now  added  0.1  c.c.  guinea-pig  complement.  Finally  to 
each  front  tube  is  added  the  proper  dose  of  antigen  emulsion 
as  determined  by  the  titration.     It  is  well  to  dilute  the  anti- 


TECHNIQUE  469 

gen  emulsion  with  0.9%  salt  solution  so  that  1  c.c.  of  the 
dilution  will  contain  the  proper  dose  of  antigen.  Salt 
solution  is  now  added  to  all  the  tubes,  front  and  rear,  so  as  to 
bring  up  the  amount  in  each  to  2  c.c,  and  the  rack  is  placed 
in  the  incubator.  At  the  end  of  one  hour  the  rack  is  taken 
out  and  to  each  tube  are  added  1  c.c.  of  5%  sheep  corpuscle 
suspension  and  the  proper  amount  of  anti-sheep  haemolytic 
amboceptor  as  determined  by  the  titration.  As  in  the  case 
of  the  antigen,  it  is  well  to  dilute  the  amboceptor  with  0.9% 
salt  solution  so  that  1  c.c.  will  contain  the  proper  amount 
of  amboceptor.  Each  test-tube  is  thoroughly  shaken  and  the 
rack  is  returned  to  the  incubator  for  two  hours  longer,  dur- 
ing which  time  the  tubes  are  frequently  taken  out,  inspected, 
and  shaken,  and  at  the  end  of  which  time  the  readings  are 
to  be  taken.  The  positive  and  negative  control  sets  are 
inspected  first,  and  if  these  are  found  to  be  all  right  the 
readings  in  the  other  tubes  are  taken  and  recorded.  The 
rear  tubes,  containing  no  antigen,  should  in  every  case  show 
complete  haemolysis;  if  any  rear  tube  shows  inhibition  of 
haemolysis  it  is  probably  due  to  non-specific  anti-comple- 
mentary power  in  the  specimen  of  serum  or  cerebro-spinal 
fluid,  as  the  case  may  be,  and  any  inhibition  of  haemolysis  in 
the  front  tube  in  such  a  case,  being  attributable  to  the  same 
cause,  is,  therefore,  inconclusive.  If  the  rear  tiibes  show 
complete  haemolysis,  inhibition  of  haemolysis  in  any  front 
tube  indicates  a  positive  reaction,  partial  haemolysis  indicates 
a  slight  or  doubtful  reaction,  and  complete  haemolysis  indi- 
cates a  negative  reaction. 


APPENDIX  III 

EXAMINATION  FOR  APHASIA 

Cases  of  organic  brain  disease  with  lesions  involving  the 
speech  areas  and  therefore  presenting  symptoms  of  aphasia 
require  a  special  method  of  examination.  An  outline  for 
guidance  in  such  examinations  was  prepared  by  Professor 
Adolf  Meyer  some  time  ago  for  use  in  the  New  York  state 
hospital  service.  It  is  here  reproduced  without  essential, 
change. 

The  examination  presupposes  a  knowledge  of  the  previous 
educational  level  of  the  patient  and  a  complete  neurological 
status,  especially  accurate  tests  of  hearing,  vision,  and 
other  senses.  Never  omit  the  question  whether  the  patient 
is  right  or  left  handed.  Give  a  general  description  of  the 
mental  condition  of  the  patient  and  his  attitude  toward  his 
needs  and  the  surroundings,  the  extent  of  attention  and 
spontaneity,  his  general  appreciation  of  the  condition  and 
of  the  purpose  of  the  examination. 

Reaction  to  words  heard:  Does  the  patient  understand 
his  own  or  others'  names,  simple  or  complicated  words, 
orders  (button  the  vest,  open  the  mouth,  show  the  tongue, 
touch  your  nose,  open  the  window,  hold  up  three  fingers)? 
Can  he  compose  words  spelled  to  him?  Does  he  pay  atten- 
tion? Does  he  depend  upon  gestures?  How  does  he  react? 
(By  repeating  the  words;  by  forming  the  question;  by  ade- 
quate answers  in  words  or  gestures?  Or  are  the  reactions 
inadequate,  paraphasic,  mere  action,  irrelevant  productions, 
or    gibberish?)     Are    there    circumlocutions?    Evasions    of 

470 


REACTIONS  TO  THINGS  HEARD,  ETC.  471 

difficult  words,  or  sticking  to  words?  Does  the  patient  pick 
out  and  handle  correctly  objects  named? 

Reactions  to  things  heard:  Does  the  patient  understand 
such  sounds  as  the  mewing  of  a  cat,  barking,  ticking  of  watch, 
jingling  of  keys  (tests  being  made  with  his  eyes  shut)?  Is 
the  intonation  of  question,  scolding,  etc.,  understood? 

Repetition  of  words  and  sentences:  Is  the  meaning  under- 
stood at  once  or  only  after  repetition,  or  not  understood 
notwithstanding  repetition?     Is  there  automatic  echolalia? 

Spontaneous  speech:  (a)  Have  the  patient  give  an  account 
of  the  onset  of  the  trouble,  of  his  admission  to  the  hospital, 
and  of  his  present  condition.  Note  to  what  extent  he  volun- 
teers speech,  opens  or  continues  conversation,  and  sum  up 
the  defects  of  speech  shown  during  these  and  subsequent 
tests.  What  is  the  extent  of  his  vocabulary?  If  possible 
secure  a  stenographic  example.  (6)  Reciting  the  alphabet, 
days  of  the  week,  months  of  the  year,  counting  from  one  to 
twenty,  forward  and  backward,  with  or  without  help,  (c) 
Calculations,  (d)  Reciting  the  Lord's  prayer,  a  poem, 
(e)  Spelling  words,  counting  words  and  syllables.  (/)  For- 
eign languages. 

Reaction  to  things  seen:  Can  the  patient  name  coins, 
key,  ring,  knife,  button,  thread,  bottle;  wool,  cotton,  and 
silk  in  various  colors;  a  book;  geometrical  figures;  the 
meaning,  forms,  and  colors  of  pictures?  Does  he  under- 
stand the  meaning  of  movements  such  as  fiddling,  shooting, 
gestures  of  threat  and  beckoning?  Is  the  mimic  appre- 
ciation disturbed  (see  also  intonation)? 

Reaction  to  things  smelted:  Can  the  patient  notice  and 
name  odors  and  identify  them  (wintergreen,  clove,  pepper- 
mint), or  point  to  the  name  on  a  list,  or  when  mentioned? 

Reaction  to  things  tasted:  Sugar,  salt,  quinine,  noticed, 
named,  or  picked  out  from  a  list,  or  when  mentioned? 

Reaction  to  things  felt  (with  eyes  shut):  Recognition 
and  naming  of  objects  (right  and  left  hand) ;  writing  on  the 
skin  (hand  and  forehead,  geometrical  figures,  numbers, 
words).     Writing  movements  with  the  flaccid  hand. 


472  EXAMINATION  FOR  APHASIA 

Reaction  to  words  seen,  reading:  (a)  Printed  letters, 
short  and  long  words,  newspaper  headings,  paragraphs;  does 
the  patient  spell  them,  read  them  in  syllables,  or  as  a  whole? 
Does  he  pronounce  correctly  and  does  he  understand?  (6) 
Abbreviations  (W.  C.  T.  U.,  Y.  M.  C.  A.,  G.  A.  R.,  U.  S.  A.), 
(c)  Written  cards  (orders,  questions);  numerals  (Arabic, 
Roman,  fractions,  multiplication),  (d)  The  patient's  own 
writing;  name,  etc. 

Is  the  sense  grasped  without  speaking  what  is  read,  or 
only  from  reading  it  aloud?  Does  the  patient  fumble  with 
his  hands?  Speak  without  grasping  the  sense?  Are  the 
helps  of  any  use,  such  as  tracing  the  letter  with  a  pencil  or 
finger,  or  by  extensive  movements  of  the  hands  and  arms? 
Is  there  much  clinging  to  previously  spoken  words?  Is 
there  any  improvement  by  repetition  and  by  helping  along? 

Writing:  (a)  Spontaneous,  a  letter  to  a  friend  with 
signature,  or  a  statement  concerning  present  condition. 
Describe  the  effort,  (h)  Writing  from  dictation:  name, 
sentences,  numerals,  abbreviations  (Y.  M.  C.  A.,  etc.). 
Calculations  in  writing,  (d)  Copying  written  or  printed 
words  and  sentences.  Does  the  patient  understand  what 
he  copies?  Copying  unfamiliar  characters,  such  as  Greek 
or  Hebrew. 

Drawing:    Triangle,   circle,  tree,  automobile;    copying. 

Music:  Is  singing  and  playing  understood?  Can  a 
tone  be  taken  correctly?  Can  the  patient  play  or  sing? 
Sing  a  tune  with  the  words?  Speak  the  words  without  the 
tune?  Can  he  read  notes?  Write  notes  (from  memory  or 
copy)? 

Mimic  and  gestures:  To  what  extent  understood  and  used? 

Internal  language:  Is  the  memory  of  places  and  topog- 
raphy motor  or  visual?  Are  forms  remembered  by  motion 
or  visually?  Can  the  patient  sound  words  mentally?  Re- 
member the  faces  of  friends?  Color  of  things,  visually  or  only 
by  word  association?  As  a  rule  conclusions  must  be  drawn 
from  the  general  composure,  adaptability,  attention;  the 
indications  of  the  number  of  letters  or  syllables  in  a  word; 


APRAXIA,  PARAPHASIA  473 

plaj'ing  with  cards,  counting  out  every  sixth  card,  etc. 
Does  the  patient  reason? 

Apraxia:    Use  of  objects,  etc. 

Analysis  of  paraphasic  symptoms:  Is  the  patient  aware 
of  the  difficulty?  Is  he  apathetic  or  indifferent,  or  making 
efforts  to  correct  himself,  or  to  substitute? 


APPENDIX  IV 
NORMAL  COURSE  OF  MENTAL  DEVELOPMENT 

From  Birth  to  Third  Year 
(From  Preyer,  Paton,  Church  and  Peterson,  and  others) 

The  study  of  the  early  years  of  infancy  resulted  long  ago 

in  the  formulation  of  outlines  showing  the  normal  course 

of  development  of  the  child.     The  following  composite  of 

several  such  outlines  represents  the  simplest  and  earliest 

type  of  age  scale  for  the  measurement  of  psychophysical 

status: 

1st  Week: — Sensitive  to  light,  reaction  to  touch,  evidences  of 
audition,  sensibility  to  taste. 

2d  Week — Notices  candle,  facial  reaction  suggesting  pleasure. 

3d  Week — Sheds  tears. 

4th  Week — Smiles  and  makes  vowel  sounds. 

1st  Month — Taste,  smell,  touch,  sight,  hearmg  active. 
Sleeps  two  hours  at  a  time,  sixteen  hours  out  of  twenty- 
four. 

2d  Month — Occasional  strabismus,  recognizes  human  voice, 
turns  head  toward  sound,  pleased  with  music  and  with 
human  faces,  laughs  at  tickling,  clasps  with  four  fingers 
by  end  of  second  month,  makes  first  consonants. 

3d  Month — Cries  with  joy  at  sight  of  mother  or  father. 
Eyelids  not  completely  raised  when  child  looks  up. 
Knows  sound  of  watch.     Listens  with  attention. 

4th  Month — Eye  movements  perfect.     Sees  objects  move 
toward  eye.     Pleased  at  seeing  self  in  mirror.     Opposes 
thumb  to  fingers.     Head  held  up  permanently.     Sits 
up  with  support  at  back.     Begins  to  imitate. 
474 


NORMAL  COURSE  OF  MENTAL  DEVELOPMENT    475 

5th  Month — Discriminates  strangers.  Enjoys  crumpHng 
and  tearing  paper,  pulhng  hair,  ringing  bell.  Sleeps 
ten  hours  without  food.  Makes  consonants  L  and  K. 
Seizes  and  carries  objects  to  mouth. 

6th  and  7th  Months — Raises  self  to  sitting  posture.  Laughs. 
Raises  and  drops  arms  when  pleasure  is  great.  Teeth 
begin  to  appear.  Astonishment  shown  by  open  mouth 
and  eyes.     Turns  head  as  sign  of  refusal. 

8th  and  9th  Month — Stands  on  feet  without  support.  Claps 
hands  for  joy.  Afraid  of  dogs.  Turns  over  when  laid 
face  down.  Turns  head  to  light  when  asked  where  it  is. 
Voice  is  more  modulated.  Questions  understood  before 
child  can  speak. 

10th  to  12th  Months — First  attempts  at  walking.  Sitting 
has  become  a  habit.  Stands  without  support.  Whis- 
pering begins.  Pushes  chair.  Obeys  command  "  Give 
me  your  hand." 

13th  to  15th  Months— Says  "  Papa  "  and  "  Mamma  " 
Raises  itself  by  chair.  Imitates  coughing  and  swinging 
of  arms.  Walks  without  support.  Understands  about 
ten  words. 

16th  to  19th  Months — Sleeps  ten  hours  at  a  time.  Associates 
words  with  objects.  Blows  horn,  strikes  with  hand  or 
foot,  waters  flowers,  tries  to  wash  hands,  to  comb  and 
brush  hair,  and  to  execute  other  imitative  movements. 

20th  to  24th  Months — Makes  marks  with  pencil  on  paper. 
Executes  simple  orders  with  surprising  accuracy. 

25th  to  30th  Months — Distinguishes  colors,  makes  sentences 
of  several  words,  begins  to  cHmb  and  jump  and  to 
ask  questions. 

30th  to  40th  Months — Goes  up  stairs  without  help. 
Clauses  formed.  Words  distinctly  spoken.  Influence 
of  dialect  appears.     Much  questioning. 

Beyond  40th  Month — See  standard  Intelligence  Scales  and 
specific  Performance  Tests. 


APPENDIX  V 

STANFORD    REVISION    OF    THE    BINET-SIMON    INTELLI- 
GENCE SCALE  1 

Materials  and  Equipment. — The  following  materials  and 
equipment  are  required: 

(1)  A  set  of  printed  cards  consisting  of  four  pictures 
used  in  3-,  7-,  and  12-year  tests;  lines  for  comparison  used  in 
4-year  test;  geometrical  forms  for  discrimination,  in  dupli- 
cate, used  in  4-year  test;  printed  colors  used  in  5-year  test; 
printed  faces  for  aesthetic  comparison  used  in  5-year  test; 
pictures  with  missing  parts  used  in  6-year  test;  designs  for 
drawing  from  memory  used  in  10-year  test;  code  used  in 
"  average  adult  "  test;  and  scoring  cards  for  square,  diamond, 
ball  and  field,  dictation,  and  designs  used  in  4-,  7-,  8-,  and  10- 
year  tests.^ 

(2)  Record  booklets,  which  are  necessary  not  only  for  the 
proper  and  convenient  recording  of  the  results  of  tests,  but 
also  because  they  contain  some  of  the  testing  equipment: 
sentences  and  digit  series  for  repetition  used  in  3,  4,  6,  7,  9, 
and  all  the  higher  age  tests;  square  used  in  4-year  test; 
diamond  used  in  7-year  test;  ball  field  used  in  8-  and  12-year 
tests;  the  correct  wording  for  comprehension  tests  used  at 
various  ages;   printed  form  for  10-year  test  for  reading  and 

^  L.  M.  Terman.  The  Measurement  of  Intelligence.  Boston,  1916. — 
We  acknowledge  gratefully  our  indebtedness  to  Professor  Terman  and 
the  publishers  of  his  book,  Houghton,  Mifflin  Company,  for  permission 
to  abstract  and  reprint  instructions  for  testing,  scoring,  etc. 

2  These  printed  materials  are  to  be  had  from  Houghton,  Mifflin 
Company,  Boston,  New  York,  or  Chicago.     Price  60  cents,  postpaid. 

476 


EXPERIMENTAL  CONDITIONS  477 

report;    and  all  problems,  fables,  vocabulary,  etc.,  used  in 
tests  at  various  ages.^ 

(3)  Weights  used  in  5-  and  9-year  tests  and  the  Healy- 
Fernald  construction  puzzle  used  in  10-year  alternative  test.^ 

(4)  The  following  articles:  coins — $1,  50  cents,  quarter, 
dime,  nickel,  thirteen  pennies;  large-sized  doorkey,  not  of 
the  Yale  type;  pocket  knife;  watch  with  second  hand; 
scissors;  three  one-cent  and  three  two-cent  stamps  mounted 
in  a  single  row  on  a  blank  card  of  suitable  size,  in  the  order 
given;  two  shoe  strings;  ordinary  lead  pencil,  pen  and  ink, 
some  cards  2  by  3  inches,  pad  of  paper,  and  a  supply  of  paper 
sheets,  thin  but  firm,  8|  by  11  inches;  a  small  rectangular 
pasteboard  box. 

Experimental  Conditions. — The  tests  should  be  conducted 
in  a  quiet  room,  located  where  the  noises  of  the  street  and 
other  outside  distractions  cannot  enter.  Generally  speaking, 
if  accurate  results  are  to  be  secured  it  is  not  permissible  to 
have  any  auditor,  besides  possibly  an  assistant  to  record 
the  responses. 

The  examiner's  first  task  is  to  win  the  confidence  of  the 
child  and  overcome  his  timidity.  In  a  majority  of  cases 
from  three  to  five  minutes  should  be  sufficient,  but  in  a  few 
cases  somewhat  more  time  is  necessary. 

Nothing  contributes  more  to  a  satisfactory  rapport  than 
praise  of  the  child's  efforts.  Under  no  circumstances  should 
the  examiner  permit  himself  to  show  displeasure  at  a  response, 
however  absurd  it  may  be. 

The  examiner  would  avoid  testing  a  child  who  was  ex- 
hausted either  from  work  or  play,  or  a  child  who  was  notice- 
ably sleepy. 

Although  we  should  always  encourage  the  child  to  beheve 
that  he  can  answer  correctly,  if  he  will  only  try,  we  must 

1  Record  booklets  are  supplied  also  by  Houghton,  Mifflin  Company, 
in  packages  of  25,  at  $2  per  package,  postpaid. 

2  These  may  be  purchased  of  C.  H.  Stoelting  Company,  3037-3047 
Carroll  Ave.,  Chicago,  111.  The  cost  of  the  weights  is  $2.50  and  of  the 
construction  puzzle  $1.50. 


478    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

avoid  the  common  practice  of  dragging  out  responses  by 
too  much  urging  and  coaxing. 

It  cannot  be  too  strongly  emphasized  that  unless  we  follow 
a  standardized  procedure  the  tests  lose  their  significance. 
The  danger  is  chiefly  that  of  unintentionally  and  uncon- 
sciously introducing  variations  which  will  affect  the  meaning 
of  the  test.  One  who  would  use  the  tests  for  any  serious 
purpose,  therefore,  must  study  the  procedure  for  each  and 
every  test  until  he  knows  it  thoroughly.  After  that  a 
considerable  amount  of  practice  is  necessary  before  one  learns 
to  avoid  slips.  During  the  early  stages  of  practice  it  is 
necessary  to  refer  to  the  printed  instructions  frequently 
in  order  to  check  up  errors  before  they  have  become 
habitual. 

In  a  few  cases  the  instruction  may  be  repeated,  if  there 
is  reason  to  think  the  chUd's  hearing  was  at  fault  or  if  some 
extraordinary  distraction  has  occurred.  But  unless  other- 
wise stated  in  the  directions,  the  repetition  of  a  question  is 
ordinarily  to  be  avoided.  Supplementary  explanations  are 
hardly  ever  permissible. 

Range  and  Order  of  Testing. — Unless  there  is  reason  to 
suspect  mental  retardation,  it  is  usually  best  to  begin  with 
the  group  of  tests  just  below  the  child's  age.  However,  if 
there  is  a  failure  in  the  tests  of  that  group,  it  is  necessary 
to  go  back  and  try  all  the  tests  of  the  previous  group.  In 
like  manner  the  examination  should  be  carried  up  the  scale 
until  a  test  group  has  been  found  in  which  all  the  tests  are 
failed. 

If  language  tests  or  memory  tests  are  given  first,  the 
child  is  likely  to  be  embarrassed.  More  suitable  to  begin 
with  are  those  which  test  knowledge  or  judgment  about 
objective  things,  such  as  the  pictures,  weights,  stamps, 
bow-knots,  colors,  coins,  counting  pennies,  number  of 
fingers,  right  and  left,  time  orientation,  ball  and  field,  paper- 
folding,  etc. 

The  tests  as  arranged  in  this  revision  are  in  the  order 
which  it  is  usually  best  to  follow,  but  one  should  not  hesi- 


SCORING  AND  RECORDING  470 

tate  to  depart  from  the  order  given  when  it  seems  best  in 
a  given  case  to  do  so. 

Scoring  and  Recording. — Each  subdivision  of  a  test 
should  be  scored  separately,  in  order  that  the  clinical  picture 
may  be  as  complete  as  possible.  This  helps  in  the  final 
evaluation  of  the  results.  It  makes  much  difference,  for 
example,  whether  success  in  repeating  six  digits  is  earned  by 
repeating  all  three  correctly  or  only  one;  or  whether  the 
child's  lack  of  success  with  the  absurdities  is  due  to  failure 
on  two,  three,  four,  or  all  of  them.  Time  should  be  re- 
corded whenever  called  for  in  the  record  blanks. 

Whenever  possible  the  entire  response  should  be  recorded. 
If  the  test  results  are  to  be  used  by  any  other  person  than 
the  examiner,  this  is  absolutely  essential. 

When  for  any  reason  it  is  not  feasible  to  record  anything 
more  than  score  marks,  success  may  be  indicated  by  the 
sign  +,  failure  by  — ,  and  half  credit  by  |.  An  exceptionally 
good  response  may  be  indicated  by  +  + ,  and  an  exceptionally 

poor  response  by .    If  there  is  a  slight  doubt  about  a 

success  or  failure  the  sign  ?  may  be  added  to  the  +  or  — . 
In  general,  however,  score  the  response  either  +  or  — , 
avoiding  half  credit  as  far  as  it  is  possible  to  do  so. 

In  addition,  the  examiner  will  need  to  take  account  of 
the  general  attitude  of  the  child  during  the  examination. 
This  is  provided  for  in  the  record  blanks  under  the  heading 
"  comments."  The  comments  should  describe  as  fully  as 
possible  the  conduct  and  attitude  of  the  child  during  the 
examination,  with  emphasis  upon  such  disturbing  factors 
as  fear,  timidity,  unwilHngness  to  answer,  overconfidence, 
carelessness,  lack  of  attention,  etc. 

Alternative  Tests. — ^The  tests  designated  as  "  alternative 
tests  "  are  not  intended  for  regular  use.  Inasmuch  as  they 
have  been  standardized  and  belong  in  the  year  group  where 
they  are  placed,  they  may  be  used  as  substitute  tests  on 
certain  occasions.  Sometimes  one  of  the  regular .  tests  is 
spoiled  in  giving  it,  or  the  requisite  material  for  it  may  not 
be  at  hand.     Sometimes  there  may  be  reason  to  suspect  that 


480    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

the  subject  has  become  acquainted  with  some  of  the  tests. 
In  such  cases  it  is  a  good  convenience  to  have  a  few  sub- 
stitutes available. 

It  is  necessary,  however,  to  warn  against  a  possible 
misuse  of  alternative  tests.  It  is  not  permissible  to  count 
success  in  an  alternative  test  as  offsetting  failure  in  a  regular 
test.  This  would  give  the  subject  too  much  leeway  of 
failure.  There  are  very  exceptional  cases,  however,  when  it 
is  legitimate  to  break  this  rule;  namely,  when  one  of  the 
regular  tests  would  be  obviously  unfair  to  the  subject  being 
tested.  In  year  X,  for  example,  one  of  the  three  alternative 
tests  should  be  substituted  for  the  reading  test  (X,  4)  in 
case  we  are  testing  a  subject  who  has  not  had  the  equivalent 
of  at  least  two  years  of  school  work.  In  year  VIII,  it  would 
be  permissible  to  substitute  the  alternative  test  of  naming 
six  coins,  instead  of  the  vocabulary  test,  in  the  case  of  a  sub- 
ject who  came  from  a  home  where  English  was  not  spoken. 

Mental  Age. — As  there  are  six  tests  in  each  age  group 
from  III  to  X,  each  test  in  this  part  of  the  scale  counts 
2  months  toward  mental  age.  There  are  eight  tests  in  group 
XII,  which,  because  of  the  omission  of  the  11-year  group, 
have  a  combined  value  of  24  months,  or  3  months  each. 
Similarly,  each  of  the  six  tests  in  XIV  has  a  value  of  4  months 
(24-^6  =  4).  The  tests  of  the  "average  adult"  group 
are  given  a  value  of  5  months  each,  and  those  of  the  "  supe- 
rior adult  "  group  a  value  of  6  months  each. 

The  rule  is:  (1)  Credit  the  subject  with  all  the  tests 
below  the  point  where  the  examination  begins  (remember- 
ing that  the  examination  goes  back  until  a  year  group  has 
been  found  in  which  all  the  tests  are  passed) ;  and  (2)  add  to 
this  basal  credit  2  months  for  each  test  passed  successfully 
up  to  and  including  year  X,  3  months  for  each  test  passed 
in  XII,  4  months  for  each  test  passed  in  XIV,  5  months 
for  each  success  in  "  average  adult,"  and  6  months  for 
each  success  in  "  superior  adult." 

Intelligence  Quotient. — The  mental  age  alone  does  not 
teU  us  what  we  want  to  know  about  a  child's  intelligence 


INTELLIGENCE  QUOTIENT  481 

status.  The  significance  of  a  given  number  of  years  of 
retardation  or  acceleration  depends  upon  the  age  of  the  child. 
A  3-year-old  child  who  is  retarded  one  year  is  ordinarily 
feeble-minded;  a  10-year-old  retarded  1  year  is  only  a  little 
below  normal.  The  child  who  at  3  years  of  age  is  retarded 
1  year  will  probably  be  retarded  2  years  at  the  age  of  6,  3 
years  at  the  age  of  9,  and  4  years  at  the  age  of  12. 

What  we  want  to  know,  therefore,  is  the  ratio  existing 
between  mental  age  and  real  age.  This  is  the  intelligence 
quotient,  or  I  Q.  To  find  it  we  simply  divide  mental  age 
(expressed  in  years  and  months)  by  real  age  (also  expressed 
in  years  and  months).  The  process  is  easier  if  we  express 
each  age  in  terms  of  months  alone  before  dividing. 

Native  intelligence,  in  so  far  as  it  can  be  measured  by 
tests  now  available,  appears  to  improve  but  little  after  the 
age  of  15  or  16  years.  Accordingly,  any  person  over  16 
years  of  age,  however  old,  is  for  purposes  of  calculating 
I  Q  considered  to  be  just  16  years  old.  If  a  youth  of  18 
and  a  man  of  60  years  both  have  a  mental  age  of  12  years, 
the  I  Q  in  each  case  is  12  —  16,  or  .75. 

The  significance  of  various  values  of  the  I  Q  is  set  forth 
elsewhere.^  Here  it  need  only  be  repeated  that  100  I  Q 
means  exactly  average  intelligence;  that  nearly  all  who  are 
below  70  or  75  I  Q  are  feeble-minded ;  and  that  the  child  of 
125  I  Q  is  about  as  much  above  the  average  as  the  high 
grade  feeble-minded  individual  is  below  the  average.  For 
ordinary  purposes  all  who  fall  between  95  and  105  I  Q 
may  be  considered  as  average  in  intelligence. 


Instructions  for  Year  III 

1.  Pointing  to  Parts  of  the  Body. — Procedure. — After 

getting  the  child's  attention,  say:  "  Shoiv  me  your  nose." 
"  Put  your  finger  on  your  nose."  Same  with  eyes,  mouth, 
and  hair. 

1  See  Chapter  I,  Part  II,  this  Manual. 


482     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Tact  is  often  necessary  to  overcome  timidity.  If  two  or 
three  repetitions  of  the  instruction  fail  to  bring  a  response, 
point  to  the  child's  chin  or  ear  and  say:  "  Is  this  your 
nosef  "  "  Nof  "  "  Then  where  is  your  nosef  "  Some- 
times, after  one  has  tried  two  or  three  parts  of  the  test 
without  eliciting  any  response,  the  child  may  suddenly  release 
his  inhibitions  and  answer  all  the  questions  promptly.  In 
case  of  persistent  refusal  to  respond  it  is  best  not  to  harass 
the  child  for  an  answer,  but  to  leave  the  test  for  a  while 
and  return  to  it  later. 

Scoring.     Three  responses  out  of  four  must  be  correct. 

2.  Naming  Familiar  Objects. — ^Procedure. — Use  a  key, 
a  penny,  a  closed  knife,  a  watch,  and  an  ordinary  lead 
pencil.  The  key  should  be  the  usual  large-sized  doorkey, 
not  one  of  the  Yale  type.  The  penny  should  not  be  too 
new,  for  the  freshly  made,  untarnished  penny  resembles  very 
little  the  penny  usually  seen.  Any  ordinary  pocket  knife 
may  be  used,  and  it  is  to  be  shown  unopened.  The  formula 
is,  "  What  is  this?  "  or,  "  Tell  me  what  this  is." 

Scoring. — There  must  be  at  least  three  correct  responses 
out  of  five.  A  response  is  not  correct  unless  the  object  is 
named.  It  is  not  sufficient  for  the  child  merely  to  show  that 
he  knows  its  use. 

3.  Enumeration  of  Objects  in  Pictures. — Procedure. — 
Use  the  three  pictures  designated  as  "  Dutch  Home," 
"  River  Scene,"  and  "  Post-Office."  Say,  "  Now  I  am 
going  to  show  you  a  pretty  picture."  Then,  holding  the 
first  one  before  the  child,  close  enough  to  permit  distinct 
vision,  say:  "  Tell  me  what  you  see  in  this  picture."  If  there 
is  no  response,  as  sometimes  happens,  due  to  embarrass- 
ment or  timidity,  repeat  the  request  in  this  form:  "Look 
at  the  picture  and  tell  me  everything  you  can  see  in  it."  If 
there  is  still  no  response,  say:  "  Show  me  the  .  .  ."  (naming 
some  object  in  the  picture).  Only  one  question  of  this  type, 
however,  is  permissible.  If  the  child  answers  correctly, 
say:  "  That  is  fine;  now  tell  me  everything  you  see  in  the 
picture."     If  the  child  names  one  or  two  things  in  a  picture 


INSTRUCTIONS  FOR  ^"EAR  III  483 

and  then  stops,  urge  him  on  by  saying,  "  And  what  else?  " 
Proceed  with  pictures  h  and  c  in  the  same  manner. 

Scoring.  The  test  is  passed  if  the  child  enumerates  as 
many  as  three  objects  in  one  picture  spontaneously;  that  is, 
without  intervening  questions  or  urging. 

4.  Giving  Sex. — Procedure. — If  the  subject  is  a  boy, 
the  formula  is:  "  Are  you  a  little  boy  or  a  little  girl?  "  If  a 
girl,  "  Are  you  a  little  girl  or  a  little  boy?  "  This  variation  in 
the  formula  is  necessary  because  of  the  tendency  in  young 
children  to  repeat  mechanically  the  last  word  of  anything 
that  is  said  to  them.  If  there  is  no  response,  say:  "  Are 
you  a  little  girl?  "  (if  a  boy);  or,  "  Are  you  a  little  boy?  " 
(if  a  girl).  If  the  answer  to  the  last  question  is  '' no  "  (or 
shake  of  the  head),  we  then  say:  "  Well,  what  are  you? 
Are  you  a  little  boy  or  a  little  girl?  "  (or  ince  versa)  . 

Scoring. — The  response  is  satisfactory  if  it  indicates  that 
the  child  has  really  made  the  discrimination,  but  we  must 
be  cautious  about  accepting  any  other  response  than  the 
direct  answer,  "  A  little  girl,"  or,  "  A  little  boy."  "  Yes  " 
and  "  no  "  in  response  to  the  second  question  must  be 
carefully  checked  up. 

5.  Giving  the  Family  Name. — Procedure. — The  child 
is  asked,  "  What  is  your  name?  "  If  the  answer,  as  often 
happens,  includes  only  the  first  name  (Walter,  for  example), 
say:  "  Yes,  but  what  is  your  other  name?  Walter  what?  '' 
If  the  child  is  silent,  or  if  he  only  repeats  the  first  name,  say: 
"  7s  your  name  Walter  .  .  f  "  (giving  a  fictitious  name,  as 
Jones,  Smith,  etc.).  This  question  nearly  always  brings  the 
correct  answer  if  it  is  known. 

Scoring. — Simply  +  or  — .  No  attention  is  paid  to  faults 
of  pronunciation. 

6.  Repeating  Six  to  Seven  Syllables. — Procedure. — Begin 
by  saying:  "  Can  you  say  '  mamma  ^?  Now,  say  '  nice 
kitty.'  "  Then  ask  the  child  to  say,  "I  have  a  little  dog." 
Speak  the  sentence  distinctly  and  with  expression,  but  in  a 
natural  voice  and  not  too  slowly.  If  there  is  no  response, 
the  first  sentence  may  be  repeated  two  or  three  times.     Then 


484     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

give  the  other  two  sentences:  "  The  dog  runs  ajter  the  cat," 
and  "In  summer  the  sun  is  hot."  A  great  deal  of  tact  is 
sometimes  necessary  to  enhst  the  child's  cooperation  in  this 
test.  If  he  cannot  be  persuaded  to  try,  the  alternative  test 
of  three  digits  may  be  substituted. 

Scoring. — The  test  is  passed  if  at  least  one  sentence  is 
repeated  without  error  after  a  single  reading.  "  Without 
error  "  is  to  be  taken  literally;  there  must  be  no  omission, 
insertion,  or  transposition  of  words.  Ignore  indistinctness 
of  articulation  and  defects  of  pronunciation  as  long  as  they 
do  not  mutilate  the  sentence  beyond  easy  recognition. 

Alternative  Test:  Repeating  Three  Digits. — Procedure. 
— Use  the  following  digits:  6-4-1,  3-5-2,  8-3-7.  Begin 
with  two  digits,  as  follows:  "Listen;  say  4-2."  "Now, 
say  6-4-1."  "  Now,  say  3-5-2,"  etc.  Pronounce  the 
digits  in  a  distinct  voice  and  with  perfectly  uniform  emphasis 
at  a  rate  just  a  little  faster  than  one  per  second.  Two  per 
second,  as  recommended  by  Binet,  is  too  rapid. 

Young  subjects,  because  of  their  natural  timidity  in  the 
presence  of  strangers,  sometimes  refuse  to  respond  to  this 
test.  With  subjects  under  five  or  six  years  of  age  it  is 
sometimes  necessary  in  such  cases  to  re-read  the  first  series 
of  digits  several  times  in  order  to  secure  a  response.  The 
response  thus  secured,  however,  is  not  counted  in  scoring, 
the  purpose  of  the  re-reading  being  merelj^  to  break  the 
child's  silence.  The  second  and  third  seiies  may  be  read 
but  once. 

Scoring. — Passed  if  the  child  repeats  correctly,  after  a 
single  reading,  one  series  out  of  the  three  series  given.  Not 
only  must  the  correct  digits  be  given,  but  the  order  also 
must  be  correct. 

Instructions  for  Year  IV 

1.  Comparison  of  Lines. — Procedure. — Present  the  ap- 
propriate accompanying  card  with  the  lines  in  horizontal 
position.     Point  to  the  lines  and   say:     "  See   these   lines. 


INSTRUCTIONS  FOR  YEAR  IV  485 

Look  closely  and  tell  me  which  one  is  longer.  Put  your  finger 
on  the  longest  one."  We  use  the  superlative  as  well  as  the 
comparative  form  of  long  because  it  is  often  more  familiar 
to  young  subjects.  If  the  child  does  not  respond,  say: 
"  Show  me  ivhich  line  is  the  biggest."  Then  withdraw  the 
card,  turn  it  about  a  few  times,  and  present  it  again  with 
the  position  of  the  two  lines  reversed,  saying:  "  Noiv  show 
me  the  longest."  Turn  the  card  again  and  make  a  third  pres- 
entation. 

Scoring. — All  three  comparisons  must  be  made  correctly; 
or  if  only  two  responses  out  of  three  are  correct,  all  three 
pairs  are  again  shown,  just  as  before,  and  if  there  is  no  error 
this  time,  the  test  is  passed.  The  standard,  therefore,  is 
three  correct  responses  out  of  three,  or  five  out  of  six. 

Sometimes  the  child  points,  but  at  no  particular  part 
of  the  card.  In  such  cases  it  may  be  difficult  to  decide 
whether  he  has  failed  to  comprehend  and  to  make  the 
discrimination  or  has  only  been  careless  in  pointing.  It  is 
then  necessary  to  repeat  the  experiment  until  the  evidence 
is  clear. 

2.  Discrimination  of  Forms. — Procedure. — First,  place 
the  circle  of  the  dupHcate  set  at  "  X,"  and  say:  "Show 
me  one  like  this,"  at  the  same  time  passing  the  finger 
around  the  circumference  of  the  circle.  If  the  child  does 
not  respond,  say:  "  Do  you  see  all  of  these  thingsf  "  (running 
the  finger  over  the  various  forms) ;  "And  do  you  see  this 
one?  "  (pointing  again  to  the  circle) ;  "  Now  find  me  another 
one  just  like  this."  Use  the  square  next,  then  the  triangle, 
and  the  others  in  any  order. 

Correct  the  child's  first  error  by  saying:  ''  No,  find  one 
just  like  this  "  (again  passing  the  finger  around  the  outline 
of  the  form  at  "  X  ").  Make  no  comment  on  errors  after 
the  first  one,  proceeding  at  once  with  the  next  form,  but 
each  time  the  choice  is  correct  encourage  the  child  with 
a  hearty  "  That's  good,"  or  something  similar. 

Scoring. — The  test  is  passed  if  seven  out  of  ten  choices 
are  correct,  the  first  corrected  error  being  counted. 


486    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

3.  Counting  Four  Pennies. — Procedure. — Place  four  pen- 
nies in  a  horizontal  row  before  the  cliild.  Say:  "  See  these 
pennies.  Count  them  and  tell  me  how  many  there  are.  Count 
them  with  your  finger,  this  way  "  (pointing  to  the  first  one 
on  the  child's  left)—"  One  "—"  Now,  go  ahead."  If  the  child 
simply  gives  the  number  (whether  right  or  wrong)  withoui; 
pointing,  say:  "  No;  count  them  with  your  finger,  this  way," 
starting  him  off  as  before.     Have  him  count  them  aloud. 

Scoring. — The  test  is  passed  only  if  the  counting  tallies 
with  the  pointing.  It  is  not  sufficient  merely  to  state  the 
correct  number  without  pointing. 

4.  Copying  a  Square. — Procedure. — Place  before  the 
child  a  cardboard  on  which  is  drawn  in  heavy  black  lines  a 
square  about  1\  inches  on  a  side.  Give  the  child  a  pencil 
and  say:  "  You  see  that  (pointing  to  the  square).  I  want  you 
to  make  one  just  like  it.  Make  it  right  here  (showing  where  it 
is  to  be  drawn).     Go  ahead.     I  know  you  can  do  it  nicely." 

Avoid  such  an  expression  as,  "I  want  you  to  draw  a 
figure  like  that."  The  child  may  not  know  the  meaning  of 
either  draw  or  figure.  Also,  in  pointing  to  the  model,  take 
care  not  to  run  the  finger  around  the  four  sides. 

Give  three  trials,  saying  each  time:  "Make  it  exactly 
like  this,"  pointing  to  model.  Make  sure  that  the  child 
is  in  an  easy  position  and  that  the  paper  used  is  held  so  it 
cannot  slip. 

Scoring. — The  test  is  passed  if  at  least  one  drawing  out  of 
the  three  is  as  good  as  those  marked  +  on  the  score  card. 
Young  subjects  usually  reduce  figures  in  drawing  from  copy, 
but  size  is  wholly  disregarded  in  scoring.  It  is  of  more  im- 
portance that  the  right  angles  be  fairly  well  preserved  than 
that  the  lines  should  be  straight  or  the  corners  entirely 
closed.     The  scoring  of  this  test  should  be  rather  liberal. 

5.  Comprehension,  First  Degree. — Procedure. — After 
getting  the  child's  attention,  say:  "  What  must  you  do  when 
you  are  sleepy?  "  If  necessary  the  question  may  be  repeated 
a  number  of  times,  using  a  persuasive  and  encouraging  tone 
of  voice.     No  other  form  of  question  may  be  substituted. 


INSTRUCTIONS  FOR  YEAR  IV  487 

About  twenty  seconds  may  be  allowed  for  an  answer,  though 
as  a  rule  subjects  of  four  or  five  years  usually  answer  quite 
promptly  or  not  at  all. 

Proceed  in  the  same  way  with  the  other  two  questions: 
"  What  ought  you  to  do  when  you  are  coldf  "  "  What  ought 
you  to  do  when  you  are  hungry?  " 

Scoring. — There  must  be  two  correct  responses  out  of 
three.  No  one  form  of  answer  is  required.  It  is  sufficient 
if  the  question  is  comprehended  and  given  a  reasonably 
sensible  answer.  The  following  are  samples  of  correct  re- 
sponses:— (a)  "Go  to  bed."  "Go  to  sleep."  ''Have  my 
mother  get  me  ready  for  bed."  "  Lie  still,  not  talk,  and 
I'll  soon  be  asleep."  (&)  "  Put  on  a  coat  "  (or  "  cloak," 
"  furs,"  "  wrap  up,"  etc.).  "  Build  a  fire."  "  Run  and  I'll 
soon  get  waim."  "  Get  close  to  the  stove."  "  Go  into  the 
house,"  or,  "  Go  to  bed,"  may  possibly  deserve  the  score 
plus,  though  they  are  somewhat  doubtful  and  are  certainly 
inferior  to  the  responses  just  given,  (c)  "  Eat  something." 
"  Drink  some  milk."  "  Buy  a  lunch."  ''  Have  my  mamma 
spread  some  bread  and  butter,"  etc. 

6.  Repeating  Four  Digits. — Procedure. — Say:  "Now, 
listen.  I  am  going  to  say  over  some  numbers  and  after  I  am 
through,  I  want  you  to  say  them  exactly  like  I  do.  Ldsten 
closely  and  get  them  just  right — 4-7-3-9."  Same  with 
2-8-5^  and  7-2-6-1.  The  examiner  should  consume 
nearly  four  seconds  in  pronouncing  each  series,  and  should 
practice  in  advance  until  this  speed  can  be  closely  approxi- 
mated. If  the  child  refuses  to  respond,  the  first  series  may 
be  repeated  as  often  as  may  be  necessary  to  prove  an  attempt, 
but  success  with  a  series  which  has  been  re-read  may  not  be 
counted.  The  second  and  third  series  may  be  pronounced 
but  once. 

Scoring. — Passed  if  the  child  repeats  correctly,  after 
a  single  reading,  one  series  out  of  the  three  series  given.  The 
order  must  be  correct. 

3-ltemative  Test:  Repeating  Twelve  to  Thirteen  Syl- 
lables.— Procedure. — Get    the    child's    attention    and    say: 


488    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

"Listen,  say  this:  '  Where  is  kitty f  '  "  After  the  child 
responds,  add:  "Now  say  this  .  .  .  ,"  reading  the  first 
sentence  in  a  natural  voice,  distinctly  and  with  expression. 
If  the  child  is  too  timid  to  respond,  the  first  sentence  may- 
be re-read,  but  in  this  case  the  response  is  not  counted. 
Re-reading  is  permissible  only  with  the  first  sentence. 

Scoring. — The  test  is  passed  if  at  least  one  sentence  is 
repeated  without  error  after  a  single  reading.  As  in  the 
alternative  test  of  year  III,  we  ignore  ordinary  indistinct- 
ness and  defects  of  pronunciation  due  to  imperfect  language 
development,  but  the  sentence  must  be  repeated  without 
addition,  omission,  or  transposition  of  words. 

Instructions  for  Year  V 

1.  Comparison  of  Weights. — Procedure. — Place  the  3- 
and  15-gram  weights  on  the  table  before  the  child  some 
2  or  3  inches  apart.  Say:  "  You  see  these  blocks.  They 
look  just  alike,  but  one  of  them  is  heavy  and  one  is  light.  Try 
them  and  tell  me  which  one  is  heavier."  If  the  child  does  not 
respond,  repeat  the  instructions,  saying  this  time,  "  Tell  me 
which  one  is  the  heaviest."  (Many  American  children  have 
heard  only  the  superlative  form  of  the  adjective  used  in  the 
comparison  of  two  objects.) 

Sometimes  the  child  merely  points  to  one  of  the  blocks  or 
picks  up  one  at  random  and  hands  it  to  the  examiner 
thinking  he  is  asked  to  guess  which  is  heaviest.  We  then 
say:  "  No,  that  is  not  the  way.  You  must  take  the  blocks  in 
your  hands  and  try  them,  like  this  "  (illustrating  by  lifting 
with  one  hand,  first  one  block,  then  the  other,  a  few  inches 
from  the  table).  Most  children  of  five  years  are  then  able 
to  make  the  comparison  correctly.  Very  young  subjects, 
however,  or  older  ones  who  are  retarded,  sometimes  adopt 
the  rather  questionable  method  of  lifting  both  weights  in 
the  same  hand  at  once.  This  is  always  an  unfavorable  sign, 
especially  if  one  of  the  blocks  is  placed  in  the  hand  on  top 
of  the  other  block. 


INSTRUCTIONS  FOR  YEAR  V  489 

After  the  first  trial,  the  weights  are  shuffled  and  again 
presented  for  comparison  as  before,  this  time  with  the  posi- 
tions reversed.  The  third  trial  follows  with  the  blocks  in  the 
same  position  as  in  the  first  trial.  Some  children  have  a 
tendency  to  stereotyped  behavior,  which  in  this  test  shows 
itself  by  choosing  always  the  block  on  a  certain  side.  Hence 
the  necessity  of  alternating  the  positions.  Reserve  com- 
mendation until  all  three  trials  have  been  given. 

Scoring. — The  test  is  passed  if  two  of  the  three  comparisons 
are  correct.  If  there  is  reason  to  suspect  that  the  successful 
responses  were  due  to  lucky  guesses,  the  test  should  be  en- 
tirely repeated. 

2.  Naming  Colors. — ^Procedure. — Point  to  the  colors  in 
the  order,  red,  yellow,  blue,  green.  Bring  the  finger  close 
to  the  color  designated,  in  order  that  there  may  be  no  mistake 
as  to  which  one  is  meant,  and  say:  "What  is  the  name  of 
that  color?  "  Do  not  say:  "  What  color  is  that?  "  or,  "  What 
kind  of  a  color  is  that?  "  Such  a  formula  might  bring  the 
answer,  "The  first  color";  or,  "A  pretty  color."  Still 
less  would  it  do  to  say:  "  Show  me  the  red,''  "  Show  me  the 
yellow,"  etc.  This  would  make  it  an  entirely  different  test, 
one  that  would  probably  be  passed  a  year  earlier  than  the 
Binet  form  of  the  experiment.  Nor  is  it  permissible,  after 
a  color  has  been  miscalled,  to  return  to  it  a;nd  again  ask  its 
name. 

Scoring. — The  test  is  passed  only  if  all  the  colors  are 
named  correctly  and  without  marked  uncertainty.  How- 
ever, prefixing  the  adjective  "  dark,"  or  "  light,"  before  the 
name  of  a  color  is  overlooked. 

3.  .Esthetic  Comparison. — Procedure. — Show  the  pairs 
in  order  from  top  to  bottom.  Say:  "  Which  of  these  two 
pictures  is  the  prettiest?  "  Use  both  the  comparative  and  the 
superlative  forms  of  the  adjective.  Do  not  use  the  question, 
"  Which  face  is  the  uglier  (ugliest)?  "  unless  there  is  some 
difficulty  in  getting  the  child  to  respond.  It  is .  not  per- 
mitted, in  case  of  an  incorrect  response,  to  give  that  part 
of  the  test  again  and  to  allow  the  child  a  chance  to  correct 


490    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

his  answer ;  or,  in  case  this  is  done,  we  must  consider  only 
the  original  response  in  scoring. 

Scoring. — The  test  is  passed  only  if  all  three  comparisons 
are  made  correctly.  Any  marked  uncertainty  is  failure. 
Sometimes  the  child  laughingly  designates  the  ugly  picture 
as  the  prettier,  yet  shows  by  his  amused  expression  that  he  is 
probably  conscious  of  its  peculiarity  or  absurdity.  In  such 
cases  "  pretty  "  seems  to  be  given  the  meaning  of  "  funny  "  or 
"  amusing."  Nevertheless,  we  score  this  response  as  failure, 
since  it  betokens  a  rather  infantile  tolerance  of  ugliness. 

4.  Giving  Definitions  in  Terms  of  Use. — ^Procedure. — 
Use  the  words:  Chair,  horse,  fork,  doll,  pencil,  and  table. 
Say:  "  You  have  seen  a  chair.  You  know  what  a  chair  is. 
Tell  me,  what  is  a  chair?  "  And  so  on  with  the  other  words, 
always  in  the  order  in  which  they  are  named  above. 

Occasionally  there  is  difficulty  in  getting  a  response,  which 
is  sometimes  due  merely  to  the  child's  unwillingness  to 
express  his  thoughts  in  sentences.  The  earlier  tests  require 
only  vv^ords  and  phrases.  In  other  cases  silence  is  due  to 
the  rather  indefinite  form  of  the  question.  The  chUd  could 
answer,  but  is  not  quite  sure  what  is  expected  of  him. 
"V\Tiatever  the  cause,  a  httle  tactful  urging  is  nearly  always 
sufl&cient  to  bring  a  response. 

The  urging  should  take  the  following  form:  "  I'm  sure 
you  know  what  a  ...  is.  You  have  seen  a  .  .  .  Now, 
tell  me,  what  is  a  ...  f  "  That  is,  we  merely  repeat  the 
question  with  a  w^ord  of  encouragement  and  in  a  coaxing 
tone  of  voice.  It  would  not  at  all  do  to  introduce  other 
questions,  like,  "  What  does  a  .  .  .  look  like?  "  or,  "  What 
is  a  .  .  .  for?  "     "  What  do  people  do  with  a  .  .  .  ?  " 

Sometimes,  instead  of  attempting  a  definition  (of  doll, 
for  example),  the  child  begins  to  talk  in  a  more  or  less  irrel- 
evant way,  as,  "I  have  a  great  big  doll.  Auntie  gave  it 
to  me  for  Christmas,"  etc.  In  such  cases  we  repeat  the  ques- 
tion, saying:  "  Yes,  but  tell  me;  what  is  a  doll?  " 

Scoring. — The  test  is  passed  in  year  V  if  four  words  out 
of  the  six  are  defined  in  terms  of  use  (or  better  than  use). 


INSTRUCTIONS  FOR  YEAR  V  491 

The  following  are  examples  of  satisfactory  responses: — 
Chair:  "  To  sit  on."  "  You  sit  on  it."  "  It  is  made  of 
wood  and  has  legs  and  back,"  etc.  Horse:  "  To  drive." 
"  To  ride."  "  What  people  drive."  "  To  pull  the  wagon." 
"  It  is  big  and  has  four  legs,"  etc.  Fork:  "  To  eat  with." 
"  To  stick  meat  with."  "It  is  hard  and  has  three  sharp 
things,"  etc.  Doll:  "  To  play  with."  "  What  you  dress 
and  put  to  bed."  "  To  rock,"  etc.  Pencil:  "  To  write 
with."  "  To  draw."  "  They  write  with  it."  "  It  is  sharp 
and  makes  a  black  mark."  Table:  "  To  eat  on."  "  What 
you  put  the  dinner  on."  "  Where  you  write."  "  It  is  made 
of  wood  and  has  legs."  Examples  of  failure  are  such 
responses  as  the  following:  "  A  chair  is  a  chair  ";  "  There 
is  a  chair";  or  simply,  ''There"  (pointing  to  a  chair). 
We  record  such  responses  without  pressing  for  a  further 
definition.  About  the  only  other  type  of  failure  is  silence. 
5.  The  Game  of  Patience. — Material. — Prepare  two 
rectangular  cards,  each  2X3  inches,  and  divide  one  of  them 
into  two  triangles  by  cutting  it  along  one  of  its  diagonals. 

Procedure. — Place  the  uncut  card  on  the  table  with  one 
of  its  longer  sides  to  the  child.  By  the  side  of  this  card,  a 
little  nearer  the  child  and  a  few  inches  apart,  lay  the  two 
halves  of  the  divided  rectangle  with  their  hypothenuses 
turned  from  each  other  as  follows : 

Then  say  to  the  child:  "  I  want  you 
to  take  these  two  pieces  (touching  the 
two  triangles)  and  put  them  together  so 
they  will  look  exactly  like  this  "  (pointing 
to  the  uncut  card).  If  the  child  hesi- 
tates, we  repeat  the  instructions  with  a 
little  urging.  Say  nothing  about  hurrying,  as  this  is  hkely 
to  cause  confusion.  Give  three  trials,  of  one  minute  each. 
If  only  one  trial  is  given,  success  is  too  often  a  result  of 
chance  moves;  but  luck  is  not  likely  to  bring  two  successes 
in  three  trials.  If  the  first  trial  is  a  failure,  move  the  cut 
halves  back  to  their  original  position  and  say:  "  No:  put 
them  together  so  they  will  look   like  this  "  (pointing  to  the 


492    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

uncut  card).  Make  no  other  comment  of  approval  or  dis- 
approval. Disregard  in  silence  the  inquiring  looks  of  the 
child  who  tries  to  read  his  success  or  failure  in  your  face. 

If  one  of  the  pieces  is  turned  over,  the  task  becomes  im- 
possible, and  it  is  then  necessary  to  turn  the  piece  back  to 
its  original  position  and  begin  over,  not  counting  this  trial. 
Have  the  under  side  of  the  pieces  marked  so  as  to  avoid 
the  risk  of  presenting  one  of  them  to  the  child  wrong 
side  up. 

Scoring. — There  must  be  two  successes  in  three  trials. 
About  the  only  difficulty  in  scoring  is  that  of  deciding  what 
constitutes  a  trial.  We  count  it  a  trial  when  the  child 
brings  the  pieces  together  and  (after  a  few  or  many  changes) 
leaves  them  in  some  position.  Whether  he  succeeds  after 
many  moves,  or  leaves  the  pieces  with  approval  in  some 
absurd  position,  or  gives  up  and  says  he  cannot  do  it,  his 
effort  counts  as  one  trial.  A  single  trial  may  involve  a 
number  of  unsuccessful  changes  of  position  in  the  two 
cards,  but  these  changes  may  not  consume  altogether  more 
than  one  minute. 

6.  Three  Commissions. — Procedure. — After  getting  up 
from  the  chair  and  moving  with  the  child  to  the  center  of 
the  room,  say:  "Now,  I  want  you  to  do  something  for  me. 
Here's  a  key.  I  want  you  to  put  it  on  that  chair  over  there; 
then  I  want  you  to  shut  (or  open)  that  door,  and  then  bring  me 
the  box  which  you  see  over  there  (pointing  in  turn  to  the  objects 
designated).  Do  you  understand?  Be  sure  to  get  it  right. 
First,  put  the  key  on  the  chair,  then  shut  (open)  the  door,  then 
bring  me  the  box  (again  pointing).  Go  ahead."  Stress  the 
words  first  and  then  so  as  to  emphasize  the  order  in  which 
the  commissions  are  to  be  executed. 

Give  the  commissions  always  in  the  above  order.  Do 
not  repeat  the  instructions  again  or  give  any  further  aid 
whatever,  even  by  the  direction  of  the  gaze.  If  the  child 
stops  or  hesitates  it  is  never  permissible  to  say:  "  What 
next?  "  Have  the  self-control  to  leave  the  child  alone  with 
his  task. 


INSTRUCTIONS  FOR  YEAR  VI  493 

Scoring. — All  three  commissions  must  he  executed  and  in 
the  proper  order.  Failure  may  result,  therefore,  either  from 
leaving  out  one  or  more  of  the  commands  or  from  changing 
the  order.     The  former  is  more  often  the  case. 

Alternative  Test :  Giving  Age. — Procedure. — The  formula 
is  simply,  "  How  old  are  youf  "  The  child  of  this  age  is, 
of  course,  not  expected  to  know  the  date  of  his  birthday, 
but  merely  how  many  years  old  he  is. 

Scoring. — About  the  only  danger  in  scoring  is  in  the 
failure  to  verify  the  child's  response.  Some  children  give 
an  incorrect  answer  with  perfect  assurance,  and  it  is  there- 
fore always  necessary  to  verify. 

Instructions  for  Year  VI 

1.  Distinguishing  Right  and  Left. — Procedure. — Say  to 

the  child:  "  Show  me  your  right  hand."  After  this  is  re- 
sponded to,  say:  "Show  me  your  left  ear."  Then:  "Show 
me  your  right  eye."  Stress  the  words  left  and  ear  rather 
strongly  and  equally;  also  right  and  eye.  If  there  is  one 
error,  repeat  the  test,  this  time  with  left  hand,  right  ear,  and 
left  eye.  Carefully  avoid  giving  any  help  by  look  of  approval 
or  disapproval,  by  glancing  at  the  part  of  the  body  indicated, 
or  by  supplementary  questions. 

Scoring. — The  test  is  passed  if  all  three  questions  are 
answered  correctly,  or  if,  in  case  of  one  error,  the  three 
additional  questions  are  all  answered  correctly.  The 
standard,  therefore,  is  three  out  of  three,  or  five  out  of  six. 

The  chief  danger  of  variation  among  different  examiners 
in  scoring  comes  from  double  responses.  For  example,  the 
child  may  point  first  to  one  ear  and  then  to  the  other. 
In  all  cases  of  double  response,  the  rule  is  to  count  the 
second  response  and  disregard  the  first.  This  holds  whether 
the  first  response  was  v/rong  and  the  second  right,  or  vice 
versa. 

2.  Finding  Omissions  in  Pictures. — Procedure. — Show 
the  pictures  to  the  child  one  at  a  time  in  the  order  in  which 


494    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

they  are  lettered,  a,  h,  c,  d.  When  the  first  picture  is  shown 
(that  with  the  eye  lacking),  say:  "  There  is  something 
wrong  with  this  face.  It  is  not  all  there.  Part  of  it  is  left  out. 
Look  carefully  and  tell  me  what  part  of  the  face  is  not  there." 
Often  the  child  gives  an  irrelevant  answer,  as,  "  The  f6ef 
are  gone,"  "  The  stomach  is  not  there,"  etc.  These  state- 
ments are  true,  but  they  do  not  satisfy  the  requirements  of 
the  test,  so  we  say:  "  No;  I  am  talking  about  the  face.  Look 
again  and  tell  me  ivhat  is  left  out  of  the  face."  If  the  correct 
response  does  not  follow,  we  point  to  the  place  where  the 
eye  should  be  and  say :  "  See,  the  eye  is  gone."  When  picture 
b  is  shown  we  say  merely:  "  What  is  left  out  of  this  facef  " 
Likewise  with  picture  c.  For  picture  d  we  say:  "  What 
is  left  out  of  this  picture?  "  No  help  of  any  kind  is  given 
unless  (if  necessary)  with  the  first  picture.  With  the  others 
we  confine  ourselves  to  the  single  question,  and  the  answer 
should  be  given  promptly,  say  .within  twenty  to  twenty* 
five  seconds. 

Scoring. — Passed  if  the  omission  is  correctly  pointed  out 
in  three  out  of  four  of  the  pictures.  Certain  minor  errors 
we  may  overlook,  such  as  "  eyes  "  instead  of  "  eye  "  for 
the  first  picture;  "  nose  and  one  ear  "  instead  of  merely 
"nose"  for  the  third;  "hands"  instead  of  "arms"  for 
the  fourth,  etc.  Errors  like  the  following,  however,  count 
as  failure:  "  The  other  eye,"  or  "  The  other  ear  "  for  the 
first  or  third;  "  The  ears  "  for  the  fourth,  etc. 

3.  Counting  Thirteen  Pennies. — Procedure. — The  pro- 
cedure is  the  same  as  in  the  test  of  counting  four  pennies 
(year  IV,  test  3).  If  the  first  response  contains  only  a  minor 
error,  such  as  the  omission  of  a  number  in  counting,  failure 
to  tally  with  the  finger,  etc.,  a  second  trial  is  given. 

Scoring. — The  test  is  passed  if  there  is  one  success  in  two 
trials.  Success  requires  that  the  counting  should  tally  with 
the  pointing.  It  is  not  sufficient  merely  to  state  the  number 
of  pennies  without  pointing,  for  unless  the  child  points  and 
counts  aloud  we  cannot  be  sure  that  his  correct  answei 
may  not  be  the  joint  result  of  two  errors  in  opposite  direc- 


INSTRUCTIONS  FOR  YEAR  VI  495 

tions  and  equal;  for  example,  if  one  penny  were  skipped  and 
another  were  counted  twice  the  total  result  would  still  be 
correct,  but  the  performance  would  not  satisfy  the  require- 
ments. 

4.  Comprehension,  Second  Degree. — Procedure. — Note 
that  the  wording  of  the  first  part  of  the  questions  is  slightly 
different  from  that  in  year  IV,  test  5. 

If  there  is  no  response,  or  if  the  child  looks  puzzled,  the 
question  may  be  repeated  once  or  twice.  The  form  of  the 
question  must  not  under  any  circumstances  be  altered. 

Scoring. — Two  out  of  three  must  be  answered  correctly. 

(a)  If  it  is  raining  when  you  start  to  school.  Satisfactory: 
— "  Take  umbrella,"  "  Bring  a  parasol,"  "  Put  on  rubbers," 
"  Wear  an  overcoat,"  etc.  This  type  of  response  occurred 
61  times  out  of  72  successes.  ''  Have  my  father  bring  me  " 
also  counts  plus. 

Unsatisfactory: — "  Go  home,"  "  Stay  at  home,"  "  Stay 
in  the  house,"  "  Have  the  rainbow,"  "  Stay  in  school,"  etc. 
"  Stay  at  home  "  is  the  most  common  failure  and  might  at 
first  seem  to  the  examiner  to  be  a  satisfactory  response. 
As  a  matter  of  fact,  this  answer  rests  on  a  shght  misunder- 
standing of  the  question,  the  import  of  which  is  that  one  is 
to  go  to  school  and  it  is  raining. 

(6)  If  you  find  that  your  house  is  on  fire.  Satisfactory: — ■ 
''  Ring  the  fire  alarm,"  "  Call  the  firemen,"  "  Call  for  help," 
"  Put  water  on  it,"  etc. 

Unsatisfactory: — The  most  common  failure,  accounting 
for  nearly  half  of  all,  is  to  suggest  finding  other  shelter; 
e.g.,  "  Go  to  the  hotel,"  "  Get  another  house,"  "  Stay  with 
your  friends,"  "Build  a  new  house,"  etc.  Others  are: 
"  Tell  them  you  are  sorry  it  burned  down,"  "  Be  careful 
and  not  let  it  burn  again,"  "  Have  it  insured,"  "  Cry," 
"  Call  the  policeman,"  etc. 

(c)  If  you  miss  your  train.  Satisfactory: — The  answer 
we  expect  is,  "  Wait  for  another,"  "  Take  the  next  car," 
or  something  to  that  effect.  This  type  of  answer  includes 
about  85%  of  the  responses  which  do  not  belong  obviously 


496    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

in  the  unsatisfactory  group.  "  Take  a  jitney  "  is  a  modern 
variation  of  this  response  which  must  be  counted  as  satis- 
factory. 

Unsatisfactory: — These  are  endless.  One  continues  to 
meet  new  examples  of  absurdity  however  many  children 
one  has  tested.  The  possibilities  are  literally  inexhaustible, 
but  the  following  are  among  the  most  common:  "  Wait  for 
it  to  come  back,"  "  Have  to  walk,"  "  Be  mad,"  "  Don't 
swear,"  "  Run  and  try  to  catch  it,"  "  Try  to  jump  on," 
"  Don't  go  to  that  place."  "  Go  to  the  next  station,"  etc. 

5.  Naming  Four  Coins. — ^Procedure. — Show  a  nickel,  a 
penny,  a  quarter,  and  a  dime,  asking  each  time:  "  What  is 
that?  "  If  the  child  misunderstands  and  answers,  "  Money," 
or  "  A  piece  of  money,"  we  say:  "  Yes,  hut  what  do  you  call 
that  piece  of  moneyf  "  Show  the  coins  always  in  the  order 
given  above. 

Scoring. — The  test  is  passed  if  three  of  the  four  questions 
are  correctly  answered.  Any  correct  designation  of  a  coin 
is  satisfactory,  including  provincialisms  like  "  two  bits " 
for  the  25-cent  piece,  etc.  If  the  child  changes  his  response 
for  a  coin,  we  count  the  second  answer  and  ignore  the  first. 
No  supplementary  questions  are  permissible.     ' 

6.  Repeating  Sixteen  to  Eighteen  Syllables. — Procedure. 
— The  instructions  should  be  given  as  follows:  "  Now,  listen.. 
I  am  going  to  say  something  and  after  I  am  through  I  want 
you  to  say  it  over  just  like  I  do.  Understand?  Listen  care- 
fully and  he  sure  to  say  exactly  what  I  say."  Then  read  the 
first  sentence  rather  slowly,  in  a  distinct  voice,  and  with 
expression.  If  the  response  is  not  too  bad,  praise  the  child's 
efforts.  Then  proceed  with  the  second  and  third  sentences, 
prefacing  each  with  an  exhortation  to  "  say  exactly  what  I 
say." 

In  this  year  and  in  the  memory-for-sentences  tests  of 
later  years  it  is  not  permissible  to  re-read  even  the  first 
sentence. 

Scoring. — The  test  is  passed  if  at  least  one  sentence  out 
of  three  is  repeated  without  error,  or  if  two  are  repeated  with 


INSTRUCTIONS  FOR  YEAR  VII  497 

not  more  than  one  error  each.  A  single  omission,  insertion, 
or  transposition  counts  as  an  error.  Faults  of  pronuncia- 
tion are  of  course  overlooked.  It  is  not  sufficient  that  the 
thought  be  reproduced  intact;  the  exact  language  must  be 
repeated. 

Alternative  Test:  Forenoon  and  Afternoon. — ^Procedure. 
— If  it  is  morning,  ask:  "  Is  it  morning  or  afternoon?  "  If  it 
is  afternoon,  put  the  question  in  the  reverse  form,  "  7s  it 
afternoon  or  morning?  " 

Scoring. — The  test  is  passed  if  the  correct  response  is 
given  with  apparent  assurance.  If  the  child  says  he  is  not 
sure  but  thinks  it  is  forenoon  (or  afternoon,  as  the  case  may 
be),  we  score  the  response  a  failure  even  if  the  answer  hap- 
pens to  be  correct.  However,  this  type  of  response  is  not 
often  encountered. 

Instructions  for  Year  VII 

1.  Giving  the  Number  of  Fingers. — Procedure. — "  How 

many  fingers  have  you  on  one  hand?  "  "  How  many  on  the 
other  hand?  "  "  How  many  on  both  hands  together?  "  If 
the  child  begins  to  count  in  response  to  any  of  the  questions, 
say:  "  No,  don't  count.  Tell  me  without  counting."  Then 
repeat  the  question. 

Scoring. — Passed  if  all  three  questions  are  answered  cor- 
rectly and  promptly  without  the  necessity  of  counting. 
Some  subjects  do  not  understand  the  question  to  include 
the  thumbs.  We  disregard  this  if  the  number  of  fingers 
exclusive  of  thumbs  is  given  correctly. 

2.  Description  of  Pictures. — ^Procedure. — Use  the  same 
pictures  as  in  III,  3,  presenting  them  always  in  the  following 
order :  Dutch  Home,  River  Scene,  Post-Office.  The  formula 
for  the  test  in  this  year  is  somewhat  different  from  that  of 
year  III.  Say:  "  What  is  this  picture  about?  What  is  this 
a  picture  of?  "  Use  the  double  question,  and  follow  the 
formula  exactly.  It  would  ruin  the  test  to  say:  "  Tell  me 
everything  you  see  in  this  picture"  for  this  form  of  question 


498     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

tends  to  provoke  the  enumeration  response  even  with  intel- 
hgent  children  of  this  age. 

When  there  is  no  response,  the  question  may  be  repeated 
as  often  as  is  necessarj^  to  break  the  silence. 

Scoring. — The  test  is  passed  if  two  of  the  three  pictures 
are  described  or  interpreted.  Interpretation,  however,  is 
seldom  encountered  at  this  age.  Often  the  response  con- 
sists of  a  mixture  of  enumeration  and  description.  The  rule 
is  that  the  reaction  to  a  picture  should  not  be  scored  plus 
unless  it  is  made  up  chiefly  of  description  (or  interpretation) . 

Picture  (a).  Satisfactory  responses: — "The  little  girl 
is  crying.  The  mother  is  looking  at  her  and  there  is  a  httle 
kitten  on  the  floor." 

"  The  mother  is  watching  the  baby,  and  the  cat  is  look- 
ing at  a  hole  in  the  floor,  and  there  is  a  lamp  and  a  table  so 
I  guess  it's  a  dining  room." 

Picture  (b).  Satisfactory  responses: — "  Some  people  in  a 
boat.  The  water  is  high  and  if  they  don't  look  out  the  boat 
will  tip  over." 

"  Some  Indians  and  a  lady  and  man.  They  are  in  a  boat 
on  the  river  and  the  boat  is  about  to  upset,  and  there  are  some 
dead  trees  going  to  fall." 

Picture  (c).  Satisfactory  responses: — "A  man  selling 
eggs  and  two  men  reading  the  paper  together  and  two  men 
watching." 

"  A  few  men  reading  a  newspaper  and  one  has  a  basket 
of  eggs  and  this  one  has  been  fisliing." 

Unsatisfactory  responses  are  those  made  up  entirely  or 
mainlj''  of  enumeration.  A  phrase  or  two  of  description 
intermingled  with  a  larger  amount  of  enumeration  counts 
minus.  Sometimes  the  description  is  satisfactoiy  as  far 
as  it  goes,  but  is  exceedingly  brief.  In  such  cases  a  Httle 
tactful  urging  {"Go  ahead,'"  etc.)  will  extend  the  response 
sufBcientty  to  reveal  its  true  character. 

3.  Repeating  Five  Digits. — Procedure. — Use:  3-1-7-5-9; 
4-2-3-8-5;  9-8-1-7-6.  Tell  the  child  to  listen  and  to  say 
after  you  just  what  you  say.     Then  read  the  first  series  of 


INSTRUCTIONS  FOR  YEAR  VII  499 

digits  at  a  slightly  faster  rate  than  one  per  second,  in  a 
distinct  voice,  and  with  perfectly  uniform  emphasis.  Avoid 
rhythm. 

In  previous  tests  with  digits,  it  was  permissible  to  re- 
read the  first  series  if  the  child  refused  to  respond.  In 
this  year,  and  in  the  digits  tests  of  later  years,  this  is  not 
permissible.  Warning  is  not  given  as  to  the  number  of 
digits  to  be  repeated.  Before  reading  each  series,  get  the 
child's  attention.  Do  not  stare  at  the  child  during  the 
response,  as  this  is  disconcerting.  Look  aside  or  at  the 
record  sheet. 

Scoring. — Passed  if  the  child  repeats  correctly,  after  a 
single  reading,  one  series  out  of  the  three  series  given.  The 
order  must  be  correct. 

4.  Tying  a  Bow-knot. — Procedure. — Prepare  a  shoe- 
string tied  in  a  bow-knot  around  a  stick.  The  knot  should 
be  an  ordinary  "  double  bow,"  with  wings  not  over  3  or  4 
inches  long.  Make  this  ready  in  advance  of  the  experiment 
and  show  the  child  only  the  completed  knot. 

Place  the  model  before  the  subject  with  the  wings  pointing 
to  the  right  and  left,  and  say:  "  You  know  what  kind  of 
knot  this  is,  don't  you?  It  is  a  how-knot.  I  want  you  to 
take  this  other  piece  of  string  and  tie  the  same  kind  of  knot 
around  my  finger.''  At  the  same  time  give  the  child  a  piece 
of  shoestring,  of  the  same  length  as  that  which  is  tied  around 
the  stick,  and  hold  out  a  finger  pointed  toward  the  child 
and  in  convenient  position  for  the  operation.  It  is  better 
to  have  the  subject  tie  the  string  around  the  examiner's 
finger  than  around  a  pencil  or  other  object  because  the  latter 
often  falls  out  of  the  string  and  is  otherwise  awkward  to 
handle. 

Some  children  who  assert  that  they  do  not  know  how  to 
tie  a  bow-knot  are  sometimes  nevertheless  successful  when 
urged  to  try.  It  is  always  necessary,  therefore,  to  secure 
an  actual  trial. 

Scoring. — The  test  is  passed  if  a  double  bow-knot  (both 
ends  folded  in)  is  made  in  not  more  than  a  minute.     A  single 


500     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

bow-knot  (only  one  end  folded  in)  counts  half  credit,  because 
children  are  often  accustomed  to  use  the  single  bow  alto- 
gether. The  usual  plain  common  knot,  which  precedes  the 
bow-knot  proper,  must  not  be  omitted  if  the  response  is  to 
count  as  satisfactory,  for  without  this  preliminary  plain  knot 
a  bow-knot  will  not  hold  and  is  of  no  value.  To  be  satis- 
factory the  knot  should  also  be  drawn  up  reasonably  close, 
not  left  gaping. 

5.  Giving  Differences  from  Memory. — Procedure. — Say: 
"  What  is  the  difference  between  a  fly  and  a  butterfly  f  "  If 
the  child  does  not  seem  to  understand,  say:  "  You  know 
flies,  do  you  notf  You  have  seen  fliesf  And  you  know  the 
butterflies!  Now,  tell  me  the  difference  between  a  fly  and  a 
butterfly.'^  Proceed  in  the  same  way  with  stone  and  egg, 
and  wood  and  glass.  A  little  coaxing  is  sometimes  necessary 
to  secure  a  response,  but  supplementary  questions  and  sug- 
gestions of  every  kind  are  to  be  avoided.  For  example, 
it  would  not  be  permissible  for  the  examiner"  to  say:  "  Which 
is  larger,  a  fly  or  a  butterfly?  "  This  would  give  the  child  his 
cue  and  he  would  immediately  answer,  "  A  butterfly."  The 
child  must  be  left  to  find  a  difference  by  himself.  Sometimes 
a  difference  is  given,  but  without  any  indication  as  to  its 
direction,  as,  for  example,  "  One  is  bigger  than  the  other  " 
(for  fly  and  butterfly).  It  is  then  permissible  to  ask:  "  Which 
is  bigger?  " 

Scoring. — Passed  if  a  real  difference  is  given  in  two  out  of 
three  comparisons.  It  is  not  necessary,  however,  that  an 
essenh'aZ  difference  be  given;  the  difference  may  be  trivial, 
only  it  must  be  a  real  one.  The  following  are  samples  of 
satisfactory  and  unsatisfactory  responses: 

Fly  and  butterfly.  Satisfactory: — "  Butterfly  is  larger." 
"  Butterfly  has  bigger  wings."  "  Fly  is  black  and  a  butter- 
fly is  not." 

Unsatisfactory: — These  are  mostly  misstatements  of 
facts;  as:  "  Fly  is  bigger."  "  Fly  has  legs  and  butterfly 
hasn't."  "  Butterfly  has  no  feet  and  fly  has."  "  Butterfly 
makes  butter." 


INSTRUCTIONS  FOR  YEAR  VII  501 

Stone  and  egg.  Satisfactory: — "  Stone  is  harder."  "  Egg 
is  softer."  "  Egg  breaks  easier."  "  Egg  breaks  and  stone 
doesn't."     "  Stone  is  heavier." 

Unsatisfactory: — "  A  stone  is  bigger  (or  smaller)  than  an 
egg."  "  A  stone  is  square  and  an  egg  is  round."  "  An  egg 
is  yellow  and  a  stone  is  white." 

Wood  and  glass.  Satisfactory: — "  Glass  breaks  easier 
than  wood."  "  Glass  breaks  and  wood  does  not."  "  Wood 
is  stronger  than  glass."  "  Glass  you  can  see  through  and 
wood  you  can't." 

Unsatisfactory: — "  Wood  is  black  and  glass  is  white." 
(Color  differences  are  always  unsatisfactory  in  this  compari- 
son unless  transparency  is  also  mentioned.)  "  Glass  is 
square  and  wood  is  round."  "  Glass  is  bigger  than 
wood." 

6.  Copying  a  Diamond. — ^Procedure. — Place  the  model 
before  the  child  with  the  longer  diagonal  pointing  directly 
toward  him,  and  giving  him  pen  and  ink  and  paper,  say: 
"  I  want  you  to  draw  one  exactly  like  this."  Give  three  trials, 
saying  each  time :  "  Make  it  exactly  like  this  one."  In  repeat- 
ing the  above  formula,  merely  point  to  the  model;  do  not 
pass  the  fingers  around  its  edge. 

Scoring. — The  test  is  passed  if  two  of  the  three  drawings 
are  at  least  as  good  as  those  marked  satisfactory  on  the 
score  card.  The  diamond  should  be  drawn  approximately 
in  the  correct  position,  and  the  diagonals  must  not  be  re- 
versed. Disregard  departures  from  the  model  with  respect 
to  size. 

Alternative  Test  1:  Naming  the  Days  of  the  Week. — 
Procedure. — Say:  "  You  know  the  days  of  the  week,  do  you 
not?  Name  the  days  of  the  week  for  me."  Sometimes  the 
child  begins  by  naming  various  annual  holidays,  as  Christ- 
mas, Fourth  of  July,  etc.  Perhaps  he  has  not  comprehended 
the  task;  at  any  rate,  we  give  him  one  more  trial  by  stop- 
ping him  and  saying:  "No;  that  is  not  what  I  mean.  I 
want  you  to  name  the  days  of  the  week."  No  supplementary 
questions  are  permissible,  and  we  must  be  careful  not  to 


502     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

show  approval  or  disapproval  in  our  looks  as  the  child  is 
giving  his  response. 

If  the  days  have  been  named  in  correct  order,  we  check 
up  the  response  to  see  whether  the  real  order  of  days  is 
known  or  whether  the  names  have  only  been  repeated  me- 
chanically. This  is  done  by  asking  the  following  questions: 
"  What  day  comes  before  Tuesday?  "  "  What  day  comes 
before  Thursday?  "     "  What  day  comes  before  Friday?  " 

Scoring. — The  test  is  passed  if,  within  fifteen  seconds,  the 
days  of  the  week  are  all  named  in  correct  order,  and  if  the 
child  succeeds  in  at  least  two  of  the  three  check  questions. 
We  disregard  the  point  of  beginning. 

Alternative  Test  2 :  Repeating  Three  Digits  Reversed. — 
Procedure.— The  digits  used  are:  2-8-3;  4-2-7;  5-9-6. 
The  test  should  be  given  after,  but  not  immediately  after, 
the  tests  of  repeating  digits  forwards. 

Say  to  the  child:  "Listen  carefully,  I  am  going  to  read 
some  numbers  again,  but  this  time  I  want  you  to  say  them 
backwards.  For  example,  if  I  should  say  1-2-3,  you  would 
say  3-2-1.  Do  you  understand?  "  When  it  is  evident  that 
the  child  has  grasped  the  instructions,  say:  "  Ready  now; 
listen  carefully,  and  be  sure  to  say  the  numbers  backwards.^' 
Then  read  the  series  at  the  same  rate  and  in  the  same  man- 
ner as  in  the  other  digits  tests.  It  is  not  permissible  to 
re-read  any  of  the  series. 

If  the  first  series  is  repeated  forwards  instead  of  back- 
wards, the  instructions  must  be  repeated.  Before  each 
series  exhort  the  child  to  listen  carefully  and  to  be  sure  to 
repeat  the  numbers  backwards. 

Scoring. — The  test  is  passed  if  one  series  out  of  three  is 
repeated  backwards  without  error. 

Instructions  for  Year  VIII 

1.  The  Ball-and-field  Test.— Procedure.— Say:  "Let 
us  suppose  that  your  baseball  has  been  lost  in  this  round  field. 
You  have  no  idea  what  part  of  the  field  it  is  in.  You  don't 
know  what  direction  it  came  from,  how  it  got  there,  or  with 


INSTRUCTIONS  FOR  YEAR  VIII  503 

what  force  it  came.  All  you  know  is  that  the  ball  is  lost  some- 
where in  the  field.  Now,  take  this  pencil  and  mark  out  a  path 
to  show  me  how  you  woidd  hunt  for  the  ball  so  as  to  be  sure  not 
to  miss  it.  Begin  at  the  gate  and  show  me  what  path  you  would 
take." 

Give  the  instructions  always  as  worded  above.  Avoid 
using  an  expression  like,  "  Shoiu  me  how  you  would  walk 
around  in  the  field  ":  the  word  around  might  suggest  a  cir- 
cular path. 

Sometimes  the  child  merely  points  or  tells  how  he  would 
go.  It  is  then  necessary  to  say:  "  No;  you  must  mark  out 
your  path  with  the  pencil  so  I  can  see  it  plainly.'^  Other 
children  trace  a  path  only  a  little  way  and  stop,  saying: 
"  Here  it  is."  We  then  say:  "  But  suppose  you  have  not 
found  it  yet.  Which  direction  woidd  you  go  nextf  "  In  this 
way  the  child  must  be  kept  tracing  a  path  until  it  is  evident 
whether  any  plan  governs  his  procedure. 

Scoring. — The  performances  secured  with  this  test  are 
conveniently  classified  into  four  groups,  representing  pro- 
gressively higher  types.  The  first  two  types  represent  fail- 
ures; the  third  is  satisfactory  at  year  VIII,  the  fourth  at 
year  XII.     They  may  be  described  as  follows: 

Type  a  (failure).  The  child  fails  to  comprehend  the 
instructions  and  either  does  nothing  at  all  or  else,  perhaps, 
takes  the  pencil  and  makes  a  few  random  strokes  which 
could  not  be  said  to  constitute  a  search. 

Type  b  (also  failure) .  The  child  comprehends  the  instruc- 
tions and  carries  out  a  search,  but  without  any  definite  plan. 
Absence  of  plan  is  evidenced  by  the  crossing  and  re-crossing 
of  paths,  or  by  "  breaks."  A  break  means  that  the  pencil 
is  lifted  up  and  set  down  in  another  part  of  the  field.  Some- 
times only  two  or  three  fragments  of  paths  are  drawn,  but 
more  usually  the  field  is  pretty  well  filled  up  with  random 
meanderings  which  cross  each  other  again  and  again.  Other 
illustra,tions  of  type  b  are:  A  single  straight  or  curved 
Hne  going  direct  to  the  ball,  short  haphazard  dashes  or 
curves,  bare  suggestions  of  a  fan  or  spiral. 


504     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Type  c  (satisfactory  at  year  VIII).  A  successful  perform- 
ance at  year  VIII  is  characterized  by  the  presence  of  a  plan, 
but  one  ill-adapted  to  the  purpose.  That  some  forethought 
is  exercised  is  evidenced,  (1)  by  fewer  crossings,  (2)  by  a 
tendency  either  to  make  the  lines  more  or  less  parallel 
or  else  to  give  them  some  kind  of  sjonmetry,  and  (3)  by  fewer 
breaks.  The  possibilities  of  type  c  are  almost  unlimited, 
and  one  is  continually  meeting  new  forms.  We  have  dis- 
tinguished more  than  twenty  of  these,  the  most  common  of 
which  may  be  described  as  follows: 

1.  Very  rough  or  zigzag  circles  or  similarly  imperfect 
spirals.  2.  Segments  of  curves  joined  in  a  more  or  less 
sjTiimetrical  fashion.  3.  Lines  going  back  and  forth  across 
the  field,  jointed  at  the  ends  and  not  intended  to  be  parallel. 
4.  The  "  wheel  plan,"  showing  lines  radiating  from  near  the 
center  of  the  field  toward  the  circumference.  5.  The  "  fan 
plan,"  showing  a  number  of  lines  radiating  (usually)  from 
the  gate  and  spreading  out  over  the  field.  6.  "  Fan  ellipses  " 
or  "  fan  spirals  "  radiating  from  the  gate  like  the  lines  just 
described.  7.  "  The  leaf  plan,"  "  rib  plan,"  or  "  tree  plan," 
with  lines  branching  off  from  a  trunk  line  like  ribs,  veins  of  a 
leaf,  or  branches  of  a  tree.  8.  Parallel  lines  which  cross  at 
right  angles  and  mark  off  the  field  like  a  checkerboard. 
9.  Paths  making  one  or  more  fairly  symmetrical  geometrical 
figures,  like  a  square,  a  diamond,  a  star,  a  hexagon,  etc.  10. 
A  combination  of  two  or  more  of  the  above  plans. 

Type  d  (satisfactory  at  year  XII) .  Performances  of  this 
type  meet  perfectly,  or  almost  perfectly,  the  logical  require- 
ments of  the  problem.  The  paths  are  almost  or  quite 
parallel,  and  there  are  no  intersections  or  breaks.  The 
possibilities  of  type  d  are  fewer  and  embrace  chiefly  the 
follomng: — 1.  A  spiral,  perfect  or  almost  perfect,  and 
beginning  either  at  the  gate  or  at  the  center  of  the  field. 
2.  Concentric  circles.  3.  Transverse  lines  parallel  or  almost 
so,  and  joined  at  the  ends. 

Grading  presents  some  difficulties  because  of  occasional 
border-line  performances  which  have  a  value  almost  mid- 


INSTRUCTIONS  FOR  YEAR  VIII  505 

way  between  types  b  and  c  or  between  c  and  d.  Frequent 
reference  to  the  scoring  card  will  enable  the  examiner, 
after  a  little  experience,  to  score  nearly  all  the  doubtful 
performances  satisfactorily. 

2.  Counting  Backwards  from  20  to  1. — Procedure. — 
Say  to  the  child:  '^You  can  count  backwards,  can  you  not? 
I  want  you  to  count  backwards  for  me  from  20  to  1.  Go  ahead." 
In  the  great  majority  of  cases  this  is  sufficient;  the  child 
comprehends  the  task  and  begins.  If  he  does  not  com- 
prehend and  is  silent,  or  starts  in,  perhaps,  to  count  forwards 
from  1  or  20,  say:  "  No;  I  want  you  to  count  backwards  from 
20  to  1,  like  this:  20-19-18,  and  clear  on  down  to  1.  Now, 
go  ahead." 

Insist  upon  the  child  trying  it  even  though  he  asserts 
he  cannot  do  it.  In  many  such  cases  an  effort  is  crowned 
with  success.  Say  nothing  about  hurrying,  as  this  confuses 
some  subjects.     Prompting  is  not  permissible. 

Scoring. — The  test  is  passed  if  the  child  counts  from  20 
to  1  in  not  over  forty  seconds  and  with  not  more  than  a  single 
error  (one  omission  or  one  transposition).  Errors  which 
the  child  spontaneously  corrects  are  not  counted  as  errors. 

3.  Comprehension,  Third  Degree. — The  procedure  is 
the  same  as  in  previous  comprehension  questions.  Each 
question  may  be  repeated  once  or  twice,  but  its  form  must 
not  be  changed.     No  explanations  are  permissible. 

Scoring. — Question  a  (If  you  have  broken  something). 
Satisfactory  responses  are  those  suggesting  either  restitution, 
or  apology,  or  both.  Confession  is  not  satisfactory  unless 
accompanied  by  apology.  The  following  are  satisfactory: 
"  Buy  a  new  one."  ''  Pay  for  it."  "  Give  them  something 
instead  of  it."     ''  Have  my  father  mend  it."     "  Apologize." 

Unsatisfactory: — "  Tell  them  I  did  it."  "  Go  tell  my 
mother."  "  Feel  sorry."  "  Be  ashamed."  "  Pick  it  up," 
etc.     Mere  confession  accounts  for  20%  of  all  failures. 

Question  b  (In  danger  of  being  tardy).  Satisfactory: — 
The  expected  response  is,  "  Hurry,"  "  Walk  faster,"  or  some- 
thing to  that  effect. 


506     STANFORD  RE\^SIOX  OF  BINET-SIMON  SCALE 

Unsatisfactory: — "  Go  to  the  principal."  "  Tell  the 
teacher  I  couldn't  help  it."  "  Have  to  get  an  excuse." 
Lack  of  success  results  oftenest  from  failure  to  get  the  exact 
shade  of  meaning  conveyed  by  the  question.  It  is  implied, 
of  com'se,  that  something  is  to  be  done  at  once  to  avoid 
tardiness;  but  the  subject  of  dull  comprehension  may  suggest 
a  suitable  thing  to  do  in  case  tardiness  has  been  incurred. 

Question  c  {Playmate  hits  you).  Satisfactory  responses 
are  onlj^  those  which  suggest  either  excusing  or  overlooking 
the  act.  These  ideas  are  variouslj^  expressed  as  follows: 
"  I  would  excuse  him  "  (about  half  of  all  the  correct  answers). 
"  I  would  say  '  yes  '  if  he  asked  my  pardon."  "  I  would  say 
it  was  all  right."     "  I  would  take  it  for  a  joke." 

Unsatisfactory  responses  are  all  those  not  of  the  above 
two  types;  as:  "  I  would  hit  them  back."  " I  would  not  hit 
them  back,  but  I  would  get  even  some  other  way."  "  Tell 
them  not  to  do  it  again." 

4.  Giving  Similarities  of  Two  Things. — ^Procedure. — 
Say  to  the  child:  ''  I  am  going  to  name  two  things  which  are 
alike  in  some  way,  and  I  want  you  to  tell  me  how  they  are  alike. 
Wood  and  coal:  in  what  way  are  they  alike?  "  Proceed  in  the 
same  manner  with:  An  apple  and  a  peach.  Iron  and 
silver.  A  ship  and  an  automobile.  After  the  first  pair  the 
formula  may  be  abbreviated  to  "  In  what  way  are  .  .  .  and 
.  .  .  alike?  "  It  is  often  necessarj^  to  insist  a  httle  if  the 
child  is  silent  or  saj^s  he  does  not  know,  but  in  doing  this  we 
must  avoid  supplementary^  questions  and  suggestions.  In 
gi^•ing  the  first  pau,  for  example,  it  would  not  be  permissible 
to  ask  such  additional  questions  as,  "  What  do  you  use  wood 
for?  What  do  you  use  coal  for?  And  now,  how  are  wood  and 
coal  alike?  "  This  is  really  putting  the  answer  in  the  child's 
mouth.  It  is  only  permissible  to  repeat  the  original  question 
in  a  persuasive  tone  of  voice,  and  perhaps  to  add:  "  I'm 
sure  you  can  tell  me  how  .  .  .  and  .  .  .  are  alike,''  or  some- 
thing to  that  effect.  TMien  a  difference  is  given,  instead  of 
a  similarity,  we  say:  "  No,  I  v:ant  you  to  tell  me  how  they  are 
alike.     In  what  way  are  .  .  .  and  .  .  .  alike?  " 


INSTRUCTIONS  FOR  YEAR  VIII  507 

Scoring. — The  test  is  passed  if  a  likeness  is  given  in  two 
out  of  four  comparisons.  We  accept  as  satisfactory  any  real 
likeness,  whether  fundamental  or  superficial,  though,  of 
course,  the  more  essential  the  resemblance,  the  better 
indication  it  is  of  intelligence.  The  follo-^-ing  are  samples 
of  satisfactory  and  unsatisfactory  answers: 

(a)  Wood  and  coal.  Satisfactory: — "  Both  keep  you 
warm."  "  Both  are  used  for  fuel."  "  Both  are  vegetable 
matter." 

Unsatisfactory: — Most  frequent  is  the  persistent  giving 
of  a  difference  instead  of  a  similarity.  This  accounts  for  a 
little  over  half  of  all  the  failures.  About  half  of  the  remainder 
are  cases  of  inability  to  give  any  response.  Incorrect  state- 
ments with  regard  to  color  are  rather  common.  Sample 
failures  of  this  type  are:  "  Both  are  black,"  or  "  Both  the 
same  color."  Other  failures  are:  "Both  are  dirty  on  the 
outside;  "  "  You  can't  break  them;  "  "  Coal  burns  better;  " 
"  Wood  is  lighter  than  coal,"  etc. 

(&)  An  apple  and  a  peach.  Satisfactory: — "  Both  are 
round."  "  Both  the  same  shape."  "  They  are  about  the 
same  color."  "  Both  nearly  always  have  some  red  on  them." 
"  Both  good  to  eat." 

Unsatisfactory: — "  Both  taste  the  same."  "  Both  have 
a  lot  of  seeds."  "  Both  have  a  fuzzy  skin."  "  An 
apple  is  bigger  than  a  peach."  "  One  is  red  and  one  is 
white,"  etc. 

(c)  Iron  and  silver.  Satisfactory: — "  Both  are  metals  " 
(or  mineral).  "Both  come  out  of  the  ground."  "Both 
cost  money."     "  Both  are  heavy." 

Unsatisfactory: — "  Both  thin  "  (or  thick).  "Sometimes 
they  are  the  same  shape."     "  Both  the  same  color." 

(d)  A  ship  and  an  automobile.  Satisfactory: — "  Both 
means  of  travel."  "  Both  go."  "  You  ride  in  them." 
"  Both  take  you  fast."     "  They  both  use  fuel." 

Unsatisfactory: — "Both  black"  (or  some  other  color). 
"  Both  very  big."  "  They  are  made  alike."  "  Both  run 
on  wheels." 


508    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

5.  Giving  Definitions   Superior  to  Use. — Procedure. — 

The  words  for  this  year  are  balloon,  tiger,  football,  and  soldier. 
Ask  simply:  "  What  is  a  balloon?  "  etc.  If  it  appears  that 
any  of  the  words  are  not  famiUar  to  the  child,  substitution 
may  be  made  from  the  following:  automobile,  battle-ship, 
potato,  store.  Make  no  comments  on  the  responses  until 
all  the  words  have  been  given.  In  case  of  silence  or  hesi- 
tation in  answering,  the  question  may  be  repeated  with  a 
little  encouragement ;  but  supplementary  questions  are  never 
in  order.  Ordinarily  there  is  no  difficulty  in  securing  a  re- 
sponse to  the  definition  test  of  this  year.  The  trouble  comes 
in  scoring  the  response. 

Scoring. — The  test  is  passed  if  two  of  the  four  words  are 
defined  in  terms  superior  to  use.  "  Superior  to  use  "  in- 
cludes chiefly:  (a)  definitions  which  describe  the  object 
or  tell  something  of  its  nature  (form,  size,  color,  appearance, 
etc.);  (b)  definitions  which  give  the  substance  or  the  mate- 
rials or  parts  composing  it ;  and  (c)  those  which  tell  what  class 
the  object  belongs  to  or  what  relation  it  bears  to  other  classes 
of  objects. 

(a)  Balloon.  Satisfactory: — "  A  balloon  is  a  means  of 
traveling  through  the  air."  "  It  is  a  kind  of  airship,  made  of 
cloth  and  filled  with  air  so  it  can  go  up."  "  It  is  big  and  made 
of  cloth.  It  has  gas  in  it  and  carries  people  up  in  a  basket 
that's  fastened  on  to  the  bottom." 

Unsatisfactory: — "  To  go  up  in  the  air."  "  What  you 
go  up  in."  "  When  you  go  up."  "  They  go  up  in  it." 
"  It's  full  of  gas." 

(b)  Tiger.  Satisfactory: — "  It  is  a  wild  animal  of  the  cat 
family."  "  It  is  an  animal  that's  a  cousin  to  the  lion." 
"  It  is  an  animal  that  lives  in  the  jungle."  "  It  is  a  wild 
animal."     "  It  looks  like  a  big  cat." 

Unsatisfactory: — "  To  eat  you  up."  "  To  kill  people." 
"  To  travel  in  the  circus."  "  What  eats  people."  "  It  is  a 
tiger,"  etc,     "  You  run  from  it." 

(c)  Football.  Satisfactory: — "  It  is  a  leather  bag  filled 
with  air  and  made  for  kicking."     "  It  is  a  ball  you  kick." 


INSTRUCTIONS  FOR  YEAR  VIII  509 

"  It  is  a  thing  you  play  with."  "It  is  made  of  leather  and 
is  stuffed  with  air." 

Unsatisfactory:—"  To  kick."  "  To  play  with."  "  What 
they  play  with."  "  Boys  play  with  it."  "  It's  filled  with 
air." 

(d)  Soldier.  Satisfactory: — "  A  man  who  goes  to  war." 
"  A  brave  man."  "  A  man  that  walks  up  and  down  and  car- 
ries a  gun." 

Unsatisfactory:— "To  shoot."  "To  go  to  war."  "It 
is  a  soldier."  "  A  soldier  that  marches."  "  He  fights." 
"  He  shoots." 

6.  Vocabulary:  Twenty  Definitions. — ^Procedure. — I^se 
the  list  of  words  given  in  the  record  booklet.  Say  to  the 
child :  "  7  want  to  find  out  how  many  words  you  know.  Listen; 
and  token  I  say  a  word  you  tell  me  what  it  means."  If  the  child 
can  read,  give  him  a  printed  copy  of  the  word  list  and  let  him 
look  at  each  word  as  you  pronounce  it. 

The  words  are  arranged  approximately  (though  not 
exactly)  in  the  order  of  their  difficulty,  and  it  is  best  to 
begin  with  the  easier  words  and  proceed  to  the  harder. 
With  children  under  9  or  10  years,  begin  with  the  first. 
Apparently  normal  children  of  10  years  may  safely  be  cred- 
ited with  the  first  10  words  without  being  asked  to  define 
them.  Apparently  normal  children  of  12  may  begin  with 
word  16,  and  15-year-olds  with  word  21.  Except  with  sub- 
jects of  almost  adult  intelligence  there  is  no  need  to  give 
the  last  10  or  15  words,  as  these  are  almost  never  correctly 
defined  by  school  children.  A  safe  rule  to  follow  is  to 
continue  until  8  or  10  successive  words  have  been  missed 
and  to  score  the  remainder  minus  without  giving  them. 

The  formula  is  as  follows:  "What  is  an  orange?" 
"  What  is  a  honfiref  "  "  Roar;  what  does  roar  mean?  " 
"Gown;  what  is  a  gown?"  "What  does  tap  mean?" 
"  What  does  scorch  mean?  "     "  What  is  a  puddle?  "  etc. 

Some  children  at  first  show  a  little  hesitation  about 
answering,  thinking  that  a  strictly  formal  definition  is  ex- 
pected.    In  such  cases  a  little  encouragement  is  necessary; 


510     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

as:  "  You  know  what  a  bonfire  is.  You  have  seen  a  bonfire. 
Now,  what  is  a  bonfire?  "  If  the  child  still  hesitates,  say: 
"  Just  tell  me  in  your  own  words;  say  it  any  way  you  please. 
All  I  want  is  to  find  out  whether  you  know  what  a  bonfire 
is."  Do  not  torture  the  child,  however,  by  undue  insist- 
ence. If  he  persists  in  his  refusal  to  define  a  word  which 
he  would  ordinarily  be  expected  to  know,  it  is  better  to 
pass  on  to  the  next  one  and  to  return  to  the  troublesome 
word  later.  Above  all,  avoid  helping  the  child  by  illustra- 
ting the  use  of  a  word  in  a  sentence.  Adhere  strictly  to  the 
formula  given  above.  If  the  definition  as  given  does  not 
make  it  clear  whether  the  child  has  the  correct  idea,  say: 
"  Explain"  or,  "  I  don't  understand;  explain  what  you 
mean." 

Encourage  the  child  frequently  by  saying:  "  That's 
fine.  You  are  doing  beautifully.  You  know  lots  of  words," 
etc.  Never  tell  the  child  his  definition  is  not  correct,  and 
never  ask  for  a  different  definition. 

Avoid  saying  anything  which  would  suggest  a  model 
form  of  definition,  as  the  type  of  definition  which  the  child 
spontaneously  chooses  throws  interesting  light  on  the  degree 
of  maturity  of  the  apperceptive  processes.  Record  all 
definitions  verbatim  if  possible,  or  at  least  those  which 
are  exceptionally  good,  poor,  or  doubtful. 

Scoring. — Credit  a  response  in  full  if  it  gives  one  correct 
meaning  for  the  word,  regardless  of  whether  that  meaning 
is  the  most  common  one,  and  regardless  of  whether  it  is 
the  original  or  a  derived  meaning.  Occasionally  half  credit 
may  be  given,  but  this  should  be  avoided  as  far  as 
possible. 

To  find  the  entire  vocabulary,  multiply  the  number  of 
words  known  by  180.  (This  list  is  made  up  of  100  words 
selected  by  rule  from  a  dictionary  containing  18,000  words.) 
Thus,  the  child  who  defines  20  words  correctly  has  a  vocabu- 
lary of  20X180  =  3600  words;  50  correct  definitions  would 
mean  a  vocabulary  of  9000  words,  etc.  The  following  are 
the   standards  for  different  years,   as  determined  by  the 


INSTRUCTIONS  FOR  YEAR  VIII  511 

vocabulary  reached  by  60  to  65%  of  the  subjects  of  the 
various  mental  levels: 

TABLE  17 

8  years 20  words vocabulary    3,600 

10  years 30  words vocabulary    5,400 

12  years 40  words vocabulary    7,200 

14  years 50  words vocabulary    9,000 

Average  adult 65  words vocabulary  11,700 

Superior  adult 75  words vocabulary  13,500 


Although  the  form  of  the  definition  is  significant,  it  is 
not  taken  into  consideration  in  scoring.  The  test  is  in- 
tended to  explore  the  range  of  ideas  rather  than  the  evolu- 
tion of  thought  forms.  When  it  is  evident  that  the  child  has 
one  fairly  correct  meaning  for  a  word,  he  is  given  full  credit 
for  it,  however  poorly  the  definition  may  have  been  stated. 

An  idea  of  the  degree  of  leniency  to  be  exercised  may  be 
had  from  the  following  examples  of  definitions,  which  are 
mostly  of  low  grade,  but  acceptable  unless  otherwise  indi- 
cated: 1.  Orange.  "An  orange  is  to  eat."  "  It  is  yellow 
and  grows  on  a  tree."  2.  Bonfire.  "  You  burn  it  outdoors." 
"  You  burn  some  leaves  or  things."  "  It's  a  big  fire." 
3.  Roar.  "  A  Hon  roars."  "  You  holler  loud."  4.  Gown. 
"  To  sleep  in."  "  It's  a  nightie."  "  It's  a  nice  gown  that 
ladies  wear."  26.  Noticeable.  "  You  notice  a  thing." 
29.  Civil.  "  Civil  War."  (Failure  unless  explained.)  "  It 
means  to  be  nice."  30.  Treasury.  Give  half  credit  for 
definitions  like  "  Valuables,"  ''Lots  of  money."  etc.;  i.e., 
if  the  word  is  confused  with  treasure.  32.  Ramble.  "  To 
go  about  fast."  73.  Harpy.  "A  kind  of  bird."  80.  Exalta- 
tion. "  You  feel  good."  85.  Retroactive.  "  Acting  back- 
ward."    92.   Theosophy.    "  A  religion." 

Alternative  Test  1:  Naming  Six  Coins. — Procedure  is 
exactly  as  in  VI,  5  (naming  four  coins).  The  dollar  should 
be  shown  before  the  half-dollar. 

Scoring. — All  six  coins  must  be  correctly  named.  If  a 
response  is  changed  the  rule  is  to  count  the  second  answer 
and  ignore  the  first. 


512    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Alternative  Test  2 :  Writing  from  Dictation. — Procedure. 

— Give  the  child  pen,  ink,  and  paper,  place  him  in  a  com- 
fortable position  for  writing,  and  say:  "  /  want  you  to  write 
something  for  me  as  nicely  as  you  can.  Write  these  words: 
'  See  the  little  hoy.'  Be  sure  to  write  it  all:  *  See  the  little 
boy.'  " 

Do  not  dictate  the  words  separately,  but  give  the  sen- 
tence as  a  whole.  Further  repetition  of  the  sentence  is  not 
permissible,  as  ability  to  remember  what  has  been  dictated 
is  a  part  of  the  test.     Copy,  of  course,  must  not  be  shown. 

Scoring. — Passed  if  the  sentence  is  written  legibly  enough 
to  be  easily  recognized,  and  if  no  word  has  been  omitted. 
Ordinary  mistakes  of  spelling  are  disregarded.  The  rule  is 
that  the  mistake  in  spelling  must  not  mutilate  the  word 
beyond  easy  recognition. 

Instructions  for  Year  IX 

1.  Giving  the  Date. — Procedure. — ^Ask  the  following 
questions  in  order:  (a)  "  What  day  of  the  week  is  it  to-day f  " 
(h)  "  What  month  is  it?  "  (c)  "  What  day  of  the  month  is 
itf  "     (d)  "  What  year  is  it?  " 

If  the  child  misunderstands  and  gives  the  day  of  the 
month  for  the  day  of  the  week,  or  vice  versa,  we  merely  repeat 
the  question  with  suitable  emphasis,  but  give  no  other 
help. 

Scoring. — An  error  of  three  days  in  either  direction  is 
allowed  for  c,  but  a,  b,  and  d  must  all  be  given  correctly., 
If  the  child  makes  an  error  and  spontaneously  corrects  it, 
the  change  is  allowed,  but  corrections  must  not  be  called  for 
or  suggested. 

2.  Arranging  Five  Weights. — Procedure. — Place  the  five 
blocks  on  the  table  in  an  irregular  group  before  the  child  and 
say:  "  See  these  blocks.  They  all  look  alike,  don't  they?  But 
they  are  not  alike.  Some  of  them  are  heavy,  some  are  not 
quite  so  heavy,  and  some  are  still  lighter.  No  two  weigh  the 
same.     Now,  I  want  you  to  find  the  heaviest  one  and  place 


INSTRUCTIONS  FOR  YEAR  IX  513 

it  here.  Then  find  the  one  that  is  just  a  little  lighter  and  put 
it  here.  Then  put  the  next  lighter  one  here,  and  the  next  lighter 
one  here,  and  the  lightest  of  all  at  this  end  (pointing  each  time 
at  the  appropriate  spot).  Do  you  understand? '^  Whatever 
the  child  answers,  in  order  to  make  sure  that  he  does  under- 
stand, we  repeat  the  instructions  thus:  ''  Remember  now, 
that  no  two  weights  are  the  same.  Find  the  heaviest  one  and 
put  it  here,  the  next  heaviest  here,  and  lighter,  lighter,  until 
you  have  the  very  lightest  here.     Ready;  go  ahead.'" 

It  is  best  to  follow  very  closely  the  formula  here  given, 
otherwise  there  is  danger  of  stating  the  directions  so  ab- 
stractly that  the  subject  could  not  comprehend  them.  A 
formula  like  "  /  want  you  to  arrange  the  blocks  in  a  gradually 
decreasing  series  according  to  weight  "  would  be  Greek  to 
most  children  of  ten  years. 

If  the  subject  still  seems  at  a  loss  to  know  what  to  do, 
the  instructions  may  be  again  repeated.  But  no  further 
help  of  any  kind  may  be  given.  Do  not  tell  the  subject 
to  take  the  blocks  one  at  a  time  in  the  hand  and  try  them, 
and  do  not  illustrate  by  hefting  the  blocks  yourself.  It  is 
a  part  of  the  test  to  let  the  subject  find  his  own  method. 

Give  three  trials,  shuffling  the  blocks  after  each.  Do  not 
repeat  the  instructions  before  the  second  and  third  trials 
unless  the  subject  has  used  an  absurd  procedure  in  the 
previous  trial. 

Scoring. — The  test  is  passed  if  the  blocks  are  arranged  in 
the  correct  order  twice  out  of  three  trials. 

3.  Making  Change. — Procedure. — Ask  the  following 
questions  in  the  order  here  given:  (a)  "  If  I  were  to  buy 
4  cents'  worth  of  candy  and  should  give  the  storekeeper  10  cents, 
how  much  money  would  I  get  backf  "  (b)  "  If  I  bought 
12  cents'  worth  and  gave  the  storekeeper  15  cents,  how  much 
would  I  get  backf  "  (c)  ''  If  I  bought  4  cents'  worth  and  gave 
the  storekeeper  25  cents,  how  much  would  I  get  backf  " 

Coins  are  not  used,  and  the  subject  is  not  allowed  the 
help  of  pencil  and  paper.  If  the  subject  forgets  the  state- 
ment of  the  problem,  it  is  permissible  to  repeat  it  once, 


514     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

but  only  once.     The  response  should  be  made  in  ten  or 
fifteen  seconds  for  each  problem. 

Scoring. — The  test  is  passed  if  one  out  of  three  problems 
is  answered  correctly  in  the  allotted  time.  In  case  two 
answers  are  given  to  a  problem,  we  follow  the  usual  rule  of 
counting  the  second  and  ignoring  the  first. 

4.  Repeating  Four  Digits  Reversed. — Procedure  and 
Scoring. — Exactly  as  in  VII,  alternate  test  2.  The  series 
are  6-5-2-8;  4-9-3-7;  3-6-2-9. 

5.  Using  Three  Words  in  a  Sentence. — ^Procedure. — 
Say:  "  You  know  what  a  sentence  is,  of  course.  A  sentence 
is  made  up  of  some  words  which  say  something.  Now,  I  am 
going  to  give  you  three  words,  and  you  must  make  up  a  sen- 
tence that  has  all  three  words  in  it.  The  three  words  are  '  boy,' 
'  hall,'  '  river'  Go  ahead  and  make  up  a  sentence  that  has 
all  three  words  in  it."  The  others  are  given  in  the  same 
way. 

Note  that  the  subject  is  not  shown  the  three  words 
written  down,  and  that  the  reply  is  to  be  given  orally. 

If  the  subject  does  not  understand  what  is  wanted,  the 
instruction  may  be  repeated,  but  it  is  not  permissible  to 
illustrate  what  a  sentence  is  by  giving  one.  There  must  be 
no  preliminary  practice. 

A  curious  misunderstanding  which  is  sometimes  encoun- 
tered comes  from  assuming  that  the  sentence  must  be  con- 
structed entirely  of  the  three  words  given.  If  it  appears 
that  the  subject  is  stumbling  over  this  difficulty,  we  ex- 
plain: "  The  three  words  must  he  put  with  some  other  words 
so  that  all  of  them  together  will  make  a  sentence." 

Nothing  is  said  about  hurrying,  but  if  a  sentence  is  not 
given  within  one  minute  the  rule  is  to  count  that  part  of 
the  test  a  failure  and  to  proceed  to  the  next  trio  of 
words. 

Give  only  one  trial  for  each  part  of  the  test. 

Do  not  specially  caution  the  child  to  avoid  giving  more 
than  one  sentence,  as  this  is  implied  in  the  formula  used  and 
should  be  understood. 


INSTRUCTIONS  FOR  YEAR  IX  515 

Scoring. — The  test  is  passed  if  two  of  the  three  sentences 
are  satisfactory.  In  order  to  be  satisfactory  a  sentence 
must  fulfill  the  following  requirements:  (1)  It  must  either 
be  a  simple  sentence,  or,  if  compound,  must  not  contain 
more  than  two  distinct  ideas;  and  (2)  it  must  not  express 
an  absurdity. 

Slight  changes  in  one  or  more  of  the  key  words  are  dis- 
regarded, as  rivers  for  river,  etc. 

(a)  Boy,  ball,  river.  Satisfactory: — "  The  boy  threw  his 
ball  into  the  river."  "  A  boy  went  to  the  river  and  took  his 
ball  with  him."  "The  boy  ran  after  his  ball  which  was 
rolling  toward  the  river."  "  The  boy  had  a  ball  and  he 
lost  it  in  the  river." 

Unsatisfactory: — "  There  was  a  boy,  and  he  bought  a  ball, 
and  it  fell  into  the  river."  "  The  boy  was  swimming  in  the 
river  and  he  was  playing  ball." 

(6)  Work,  money,  men.  Satisfactory: — "  Men  work  and 
they  earn  money." 

Unsatisfactory: — "  Men  work  with  their  money." 

(c)  Desert,  rivers,  lakes.  Satisfactory: — "  The  desert 
has  one  river  and  one  lake."  "  There  was  a  desert  and  near 
by  there  was  a  river  that  emptied  into  a  lake." 

Unsatisfactory: — "  A  desert  is  dry,  rivers  are  long,  lakes 
are  rough."     "  The  desert  is  full  of  rivers  and  lakes." 

6.  Finding  Rhymes. — Procedure. — Say  to  the  child: 
"  You  know  what  a  rhyme  is,  of  course.  A  rhyme  is  a  word 
that  sounds  like  another  word.  Two  words  rhijme  if  they  end 
in  the  same  sound.  Understand?  "  Whether  the  child  says 
he  understands  or  not,  we  proceed  to  illustrate  what  a  rhyme 
is,  as  follows:  "  Take  the  two  words  '  hat '  and  '  cat.'  They 
sound  alike  and  so  they  make  a  rhyme.  '  Hat,'  '  rat,'  '  cat,' 
'  bat '  all  rhyme  with  one  another." 

That  is,  we  first  explain  what  a  rhyme  is  and  then  we 
give  an  illustration.  A  large  majority  of  American  children 
who  have  reached  the  age  of  nine  years  understand  per- 
fectly what  a  rhyme  is,  without  any  illustration.  A  few, 
however,  think  they  understand,  but  do  not;   and  in  order 


516     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

to  insure  that  all  are  given  equal  advantage  it  is  necessary 
never  to  omit  the  illustration. 

After  the  illustration  say:  "Now  I  am  going  to  give  you 
a  word  and  you  will  have  one  minute  to  find  as  many  words 
as  you  can  rhyme  with  it.  The  word  is  '  day.'  Name  all 
the  words  you  can  think  of  that  rhyme  with  '  day.'  '' 

If  the  child  fails  with  the  first  word,  before  giving  the 
second  we  repeat  the  explanation  and  give  sample  rhymes 
for  day;  otherwise  we  proceed  without  further  explanation 
to  mill  and  spring,  saying,  "Now,  you  have  another  minute 
to  name  all  the  words  you  can  think  of  that  rhyme  with  '  mill,'  " 
etc.  Apart  from  the  mention  of  "  one  minute  "  say  nothing 
to  suggest  hurrying,  as  this  tends  to  throw  some  children 
into  mental  confusion. 

Scoring. — Passed  if  in  two  out  of  three  parts  of  the  ex- 
periment the  child  finds  three  words  which  rhyme  with 
the  word  given,  the  time  limit  for  each  series  being  one 
minute.  Note  that  in  each  case  there  must  be  three  words 
in  addition  to  the  word  given.  These  must  be  real  words, 
not  meaningless  syllables  or  made-up  words.  However,  we 
should  be  liberal  enough  to  accept  such  words  as  ding 
(from  "  ding-dong  ")  for  spring,  Jill  (see  "  Jack  and  Jill  ") 
for  mill,  Fay  (girl's  name)  for  day,  etc. 

Alternative  Test  1 :  Naming  the  Months. — Procedure. — 
Simply  ask  the  subject  to  "  name  all  the  months  of  the  year." 
Do  not  start  him  off  by  naming  one  month;  give  no  look 
of  approval  or  disapproval  as  the  months  are  being  named, 
and  make  no  suggestions  or  comments  of  any  kind. 

When  the  months  have  been  named,  we  "  check  up  " 
the  performance  by  asking:  "  What  month  comes  before 
April?  "  "  What  month  comes  before  July? "  "  What 
month  comes  before  November?  " 

Scoring. — Passed  if  the  months  are  named  in  about  fifteen 
or  twenty  seconds  with  no  more  than  one  error  of  omission, 
repetition,  or  displacement,  and  if  two  out  of  the  three  check 
questions  are  answered  correctly.  Disregard  place  of 
beginning. 


INSTRUCTIONS  FOR  YEAR  X  517 

Alternative  Test  2:  Counting  the  Value  of  Stamps. — 
Procedure. — Place  before  the  subject  a  cardboard  on  which 
are  pasted  three  1-cent  and  three  2-cent  stamps  arranged 
as  follows:  111222.  Be  sure  to  lay  the  card  so  that  the 
stamps  will  be  right  side  up  for  the  child.  Say:  "  You 
know,  of  course,  how  much  a  stamp  like  this  costs  (pointing 
to  a  1-cent  stamp).  And  you  know  how  much  one  like  this 
costs  (pointing  to  a  2-cent  stamp).  Now,  how  much  money 
would  it  take  to  buy  all  these  stamps?  " 

Do  not  tell  the  individual  values  of  the  stamps  if  these 
are  not  known,  for  it  is  a  part  of  the  test  to  ascertain  whether 
the  child's  spontaneous  curiosity  has  led  him  to  find  out 
and  remember  their  values.  If  the  individual  values  are 
known,  but  the  first  answer  is  wrong,  a  second  trial  may 
be  given.  In  such  cases,  however,  it  is  necessary  to  be  on 
guard  against  guessing. 

If  the  child  merely  names  an  incorrect  sum  without  saying 
anything  to  indicate  how  he  arrived  at  his  answer,  it  is  well 
to  tell  him  to  figure  it  up  aloud.     "  Tell  7ne  how  you  got  it." 

Scoring. — Passed  if  the  correct  value  is  given  in  not  over 
fifteen  seconds. 

Insteuctions  for  Year  X 

1.  Vocabulary :  Thirty  Definitions. — Procedure  and  scor- 
ing as  in  VIII,  6.  At  year  X,  thirty  words  should  be  cor- 
rectly defined. 

2.  Detecting  Absurdities. — Procedure. — Say  to  the  child: 
"  I  am  going  to  read  a  sentence  which  has  something  foolish 
in  it,  some  nonsense.  I  want  you  to  listen  carefully  and  tell 
me  what  is  foolish  about  it."  Then  read  the  sentences,  rather 
slowly  and  in  a  matter-of-fact  voice,  sajdng  after  each: 
"  What  is  foolish  about  that?  " 

Each  should  ordinarily  be  answered  within  thirty  seconds. 
If  the  child  is  silent,  the  sentence  should  be  repeated;  but 
no  other  questions  or  suggestions  of  any  kind  are  permis- 
sible.    Such  questions  as  "  Could  the  road  he  downhill  both 


518     STANFORD  REVISION  OF  BINT:T-SIM0N  SCALE 

ways?  "  or,  "  Do  you  think  the  girl  could  have  killed  herself?  " 
would,  of  course,  put  the  answer  in  the  child's  mouth.  It 
is  even  best  to  avoid  laughuig  as  the  sentence  is  read. 

Owing  to  the  child's  limited  power  of  expression  it  is 
not  always  easy  to  judge  from  the  answer  given  whether 
the  absurditj''  has  really  been  detected  or  not.  In  such 
cases  ask  him  to  explain  himself,  using  some  such  formula 
as:  "  /  am  not  sure  I  know  what  you  mean.  Explain  what 
you  mean.  Tell  me  what  is  foolish  in  the  sentence  I  read  J' 
This  usuallj^  brings  a  reply  the  correctness  or  incorrectness 
of  which  is  more  apparent,  while  at  the  same  time  the  for- 
mula is  so  general  that  it  affords  no  hint  as  to  the  correct 
answer.  Additional  questions  must  be  used  with  extreme 
caution. 

Scoring. — Passed  if  the  absiudity  is  detected  in  four  out 
of  the  five  statements. 

(a)  The  road  downhill.  Satisfactory: — "  If  it  was 
do-^Tihill  to  the  city  it  would  be  uphill  coming  back." 
"  It  can't  be  downhill  both  directions."  "  That  could 
not  be." 

Unsatisfactory: — "  Perhaps  he  took  a  httle  different  road 
coming  back."  '"'  I  guess  it  is  a  veiy  crooked  road."  "  Com- 
ing back  he  goes  around  the  hill."  "  The  man  hves  do-^m 
in  a  valle3^" 

(6)  What  the  engineer  said.  Satisfactory: — "  If  he  has 
more  cars  he  will  go  slower."  '"  It  is  the  other  way.  If  he 
wants  to  go  faster  he  must  not  have  so  many  cars." 

Unsatisfactory: — "  A  long  train  is  nicer."  "  The  engine 
pulls  harder  if  the  train  has  lots  of  cars." 

(c)  The  girl  who  was  thought  to  have  killed  herself.  Satis- 
factory:— "  She  could  not  have  cut  herself  into  eighteen 
pieces."  "  She  would  have  been  dead  before  that."  "  She 
might  have  cut  two  or  three  pieces  oft',  but  she  couldn't 
do  the  rest." 

Utisatisfactory: — "  Think  that  she  killed  herself;  they 
know  she  did."  "  They  can't  be  sure.  Someone  may  have 
knied  her."     "  It  was  a  foohsh  girl  to  kiU  herself." 


INSTRUCTIONS  FOR  YEAR  X  519 

(d)  The  railroad  accident.  Satisfactory: — "  That  was 
very  serious."  "  I  should  Hke  to  know  what  you  would  call 
a  serious  accident!" 

Unsatisfactory: — "  It  was  a  foolish  mistake  that  made 
the  accident."  "  They  couldn't  help  it.  It  was  an  acci- 
dent." 

(e)  The  bicycle  rider.  Satisfactory: — "  How  could  he 
get  well  after  he  was  already  killed?  "  "  Why,  he's  already 
dead." 

Unsatisfactory: — "  Foolish  to  fall  off  a  bicycle.  He 
should  have  known  how  to  ride."  "  They  ought  to  have 
carried  him  home.     (Why?)     So  his  folks  could  get  a  doctor." 

3.  Drawing  Designs  from  Memory. — Procedure. — Use 
the  designs  shown  on  the  printed  form.  If  copies  are  used 
they  must  be  exact  in  size  and  shape.  Before  showing  the 
card  say:  "This  card  has  two  dravnngs  on  it.  I  am  going 
to  show  them  to  you  for  ten  seconds,  then  I  will  take  the  card 
away  and  let  you  draw  from  memory  what  you  have  seen. 
Examine  both  draudngs  carefully  and  remember  that  you  have 
only  ten  seconds." 

Provide  pencil  and  paper  and  then  show  the  card  for 
ten  seconds,  holding  it  at  right  angles  to  the  child's  line  of 
vision  and  with  the  designs  in  the  position  given  in  the 
plate.  Have  the  child  draw  the  designs  immediately  after 
they  are  removed  from  sight. 

Scoring. — The  test  is  passed  if  one  of  the  designs  is  repro- 
duced correctly  and  the  other  about  half  correctly.  "  Correctly  " 
means  that  the  essential  plan  of  the  design  has  been  grasped 
and  reproduced.  Ordinary  irregularities  due  to  lack  of 
motor  skill  or  to  hasty  execution  are  disregarded.  "  Half 
correctly  "  means  that  some  essential  part  of  the  design 
has  been  omitted  or  misplaced,  or  that  parts  have  been 
added. 

The  sample  reproductions  shown  on  the  scoring  card 
will  serve  as  a  guide.  It  will  be  noted  that  an  inverted 
design,  or  one  whose  right  and  left  sides  have  been  trans- 
posed, is  counted  only  half  correct,  however  perfect  it  may 


520    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

be  in  other  respects;  also  that  design  h  is  counted  only  half 
correct  if  the  inner  rectangle  is  not  located  off  center. 

4.  Reading  for  Eight  Memories. — Procedure. — Hand 
the  selection  to  the  subject,  who  should  be  seated  com- 
fortably in  a  good  light,  and  say:  "  I  want  you  to  read  this 
for  me  as  nicely  as  you  can."     The  subject  must  read  aloud. 

Pronounce  all  the  words  which  the  subject  is  unable  to 
make  out,  not  allowing  more  than  five  seconds'  hesitation 
in  such  a  case. 

Record  all  errors  made  in  reading  the  selection,  and  the 
exact  time.  By  "  error  "  is  meant  the  omission,  substitu- 
tion, transposition,  or  mispronunciation  of  one  word. 

The  subject  is  not  warned  in  advance  that  he  will  be 
asked  to  report  what  he  has  read,  but  as  soon  as  he  has 
finished  reading,  put  the  selection  out  of  sight  and  say: 
"Very  well  done.  Now,  I  want  you  to  tell  me  what  you 
read.  Begin  at  the  first  and  tell  everything  you  can  remember." 
After  the  subject  has  repeated  everything  he  can  recall  and 
has  stopped,  say:  "And  what  elsef  Can  you  remember  any 
more  of  it?  "  Give  no  other  aid  of  any  kind.  It  is  of  course 
not  permissible,  when  the  child  stops,  to  prompt  hun  with 
such  questions  as,  "And  what  next?  Where  were  the  houses 
burned?  What  happened  to  the  fireman?  "  etc.  The  report 
must  be  spontaneous. 

Now  and  then,  though  not  often,  a  subject  hesitates  or 
even  refuses  to  try,  sajang  he  is  unable  to  do  it.  Perhaps 
he  has  misunderstood  the  request  and  thinks  he  is  expected 
to  repeat  the  selection  word  for  word,  as  in  the  tests  of 
memory  for  sentences.  We  urge  a  little  and  repeat:  "Tell 
me  in  your  own  words  all  you  can  remember  of  it."  Others 
misunderstand  in  a  different  way,  and  thinking  they  are 
expected  to  tell  merely  what  the  story  is  about,  they  say: 
"  It  was  about  some  houses  that  burned."  In  such  cases  we 
repeat  the  instructions  with  special  emphasis  on  the  words 
all  you  can  remember. 

Scoring. — The  test  is  passed  if  the  selection  is  read  in 
thirty-five  seconds  with  not  more  than  two  errors,  and  if  the 


INSTRUCTIONS  FOR  YEAR  X  521 

report  contains  at  least  eight  ''  memories.'^  By  underscoring 
the  memories  correctly  reproduced,  and  by  interlineations 
to  show  serious  departures  from  the  text,  the  record  can 
be  made  complete  with  a  minimum  of  trouble. 

The  main  difficulty  in  scoring  is  to  decide  whether  a 
memory  has  been  reproduced  correctly  enough  to  be  counted. 
Absolutely  literal  reproduction  is  not  expected.  The 
rule  is  to  count  all  memories  whose  thought  is  reproduced 
with  only  minor  changes  in  the  wording.  "  It  took  quite 
a  while  "  instead  of  "it  took  some  time  "  is  satisfactory; 
likewise,  "got  burnt"  for  "was  burned";  "who  was 
sleeping"  for  "who  was  asleep";  "are  homeless"  for 
"  lost  their  homes  ";  "in  the  middle  "  for  "  near  the  center  "; 
"  a  big  fire  "  for  "  a  fire,"  etc. 

Memories  as  badly  mutilated  as  the  following,  however, 
are  not  counted:  "  A  lot  of  buildings  "  for  "  three  houses;  " 
"a  man"  for  "a  fireman";  "who  was  sick"  for  "who 
was  asleep  ";  etc.  Occasionally  we  may  give  half  credit, 
as  in  the  case  of  "  was  seventeen  thousand  dollars  "  for 
"was  fifty  thousand  dollars";  "and  fifteen  families"  for 
"  and  seventeen  families,"  etc. 

5.  Comprehension,  Fourth  Degree. — The  procedure  is 
the  same  as  for  the  previous  comprehension  tests.  Each 
question  may  be  repeated,  but  its  form  must  not  be  changed. 
It  is  not  permissible  to  make  any  explanation  whatever  as  to 
the  meaning  of  the  question,  except  to  substitute  beginning 
for  undertaking  when  (6)  seems  not  to  be  comprehended. 

Scoring. — Tivo  out  of  the  three  questions  must  be  answered 
satisfactorily.  Study  of  the  following  classified  responses 
should  make  scoring  fairly  easy  in  most  cases: 

(a)  When  someone  asks  your  opinion.  Satisfactory: — 
"  I  would  say  I  don't  know  him  very  well  "  (42%  of  the 
correct  answers).  "  Tell  him  what  I  know  and  no  more  " 
(34%  of  correct  answers).  "  I  would  say  that  I'd  rather 
not  express  any  opinion  about  him  "  (20%  of  the  correct 
answers).  "Tell  him  to  ask  someone  else."  "I  would 
not  express  any  opinion." 


522     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Unsatisfactory: — Unsatisfactory  responses  are  due  either 
to  failure  to  grasp  the  import  of  the  question,  or  to  inabil- 
ity to  suggest  the  appropriate  action  demanded  by  the 
situation. 

The  latter  form  of  failure  is  the  more  common;  e.g.: 
"  I'd  say  they  are  nice."  "  Say  you  like  them."  "  Say 
what  I  think." 

(6)  Before  undertaking  something  important.  Satisfac- 
tory:— "  Think  about  it."  "  Get  everything  ready."  "  Ask 
advice."  "  Try  something  easier  first."  "  See  whether  it 
would  be  possible." 

Unsatisfactory: — "  Promise  to  do  your  best."  "  Begin 
at  the  beginning."  "  Do  what  is  right."  "  Just  start 
doing  it." 

(c)  Why  we  should  judge  a  person  more  by  his  actions  than 
by  his  words.  Satisfactory: — "  He  might  talk  nice  and  do 
bad  things."  "  You  can  tell  by  his  actions  whether  he  is 
good  or  not."  "  Because  you  can't  always  believe  what 
people  say."  "  He  might  talk  ugly  and  still  not  do  bad 
things." 

Unsatisfactory: — "  It  shows  he  is  polite  if  he  acts  nice." 
"  A  fellow  don't  know  what  he  says."  "  If  he  doesn't 
act  right  you  know  he  won't  talk  right."  "  Might  get 
embarrassed  and  not  talk  good." 

6.  Naming  Sixty  Words. — ^Procedure. — Say:  "Now,  I 
want  to  see  how  many  different  words  you  can  name  in  three 
minutes.  When  I  say  ready,  you  must  begin  and  name  the 
words  as  fast  as  you  can,  and  I  will  count  them.  Do  you 
understand?  Be  sure  to  do  your  very  best,  and  remember  that 
just  any  words  will  do,  like  '  clouds,'  '  dog,'  '  chair,'  *  happy  ' 
— Ready;  go  ahead !  " 

The  instructions  may  be  repeated  if  the  subject  does 
not  understand  what  is  wanted.  As  a  rule  the  task  is  com- 
prehended instantly  and  entered  into  with  great  zest. 

Do  not  stare  at  the  child,  and  do  not  say  anything  as  the 
test  proceeds  unless  there  is  a  pause  of  fifteen  seconds. 
In  this  event  say:    "Go  ahead,  as  fast  as  you  can.     Any 


INSTRUCTIONS  FOR  YEAR  X  523 

words  will  do."     Repeat  this  urging  after  everj-  pause  of 
fifteen  seconds. 

Some  subjects,  usually  rather  intelligent  ones,  hit  upon 
the  device  of  counting  or  putting  words  together  in  sen- 
tences. We  then  break  in  with:  "Counting  (or  sentences, 
as  the  case  may  be)  not  allowed.  You  must  name  separate 
words.    Go  ahead." 

Record  the  individual  words  if  possible,  and  mark  the 
end  of  each  half-minute.  If  the  words  are  named  so  rapidly 
that  they  cannot  be  taken  down,  it  is  easy  to  keep  the  count 
by  making  a  pencil  stroke  for  each  word.  If  the  latter 
method  is  employed,  repeated  words  may  be  indicated  by 
making  a  cross  instead  of  a  single  stroke.  Always  make 
record  of  repetitions. 

Scoring. — The  test  is  passed  if  sixty  words,  exclusive  of 
repetition,  are  named  in  three  minutes.  It  is  not  allow- 
able to  accept  twenty  words  in  one  minute  or  forty  words 
in  two  minutes  as  an  equivalent  of  the  expected  score. 
Only  real  words  are  counted. 

Alternative  Test  1:  Repeating  Six  Digits. — The  digits 
series  used  are  3-7^-8-5-9  and  5-2-1-7-4-6. 

The  procedure  and  scoring  are  the  same  as  in  VII,  3, 
except  that  only  two  trials  are  given,  one  of  which  must  be 
correct. 

Alternative  Test  2:  Repeating  Twenty  to  Twenty-two 
Syllables. — Procedure  and  scoring  exactly  as  in  VI,  6. 

Alternative  Test  3:  Construction  Puzzle  (Healy  and 
Femald). — ^Procedure. — Place  the  frame  on  the  table  before 
the  subject,  the  short  side  nearest  him.  The  blocks  are 
placed  in  an  irregular  position  on  the  side  of  the  frame 
away  from  the  subject.  Take  care  that  the  board  with  the 
blocks  in  place  is  not  exposed  to  view  in  advance  of  the 
experiment. 

Say:  "I  want  you  to  put  these  blocks  in  this  frame  so 
that  all  the  space  will  he  filled  up.  If  you  do  it  rightly  they 
will  all  fit  in  and  there  will  he  no  space  left  over.    Go  ahead." 

Do  not  tell  the  subject  to  see  how  quickly  he  can  do  it. 


524    STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Say  nothing  that  would  even  suggest  hurrying,  for  this 
tends  to  call  forth  the  trial-and-error  procedure  even  with 
intelligent  subjects. 

Scoring. — The  test  is  passed  if  the  child  succeeds  in  fit- 
ting the  blocks  into  place  three  times  in  a  total  time  of  five 
minutes  for  the  three  trials. 

Instructions  for  Year  XII 

1.  Vocabulary :  Forty  Definitions. — Procedure  and  scor- 
ing as  in  previous  vocabulary  tests. 

2.  Defining  Abstract  Words. — Procedure. — The  words  to 
be  defined  are  pity,  revenge,  charity,  envy,  and  justice.  The 
formula  is,  "  What  is  pity?  What  do  we  mean  hy  pityf  " 
and  so  on  with  the  other  words.  If  the  meaning  of  the  re- 
sponse is  not  clear,  ask  the  subject  to  explain  what  he  means. 
If  the  definition  is  in  terms  of  the  word  itself,  as  "  Pity 
means  to  pity  someone."  "  Revenge  is  to  take  revenge," 
etc.,  it  is  then  necessary  to  say:  "  Yes,  but  what  does  it 
mean  to  pity  someone?  "  or,  "  What  does  it  mean  to  take 
revenge?  "  etc.  Only  supplementary  questions  of  this  kind 
are  permissible. 

Scoring. — The  test  is  passed  if  three  of  the  five  words  are 
satisfactorily  defined.  The  definition  need  not  be  strictly 
logical  nor  the  language  elegant.  It  is  sufficient  if  the  defi- 
nition shows  that  the  meaning  of  the  word  is  known.  Defi- 
nitions which  define  by  means  of  an  illustration  are  ac- 
ceptable. The  following  are  samples  of  satisfactory  and 
unsatisfactory  responses : 

(a)  Pity.  Satisfactory: — "  To  be  sorry  for  someone." 
"  If  anybody  gets  hurt  real  bad  you  pity  them."  "  You  see 
something  that's  wrong  and  have  your  feeling  aroused." 

Unsatisfactory: — ''  To  think  of  the  poor."  "  To  cheer 
people  up."     "  It's  when  you  break  something." 

(6)  Revenge.  Satisfactory: — "  To  get  even  with  some- 
one." "  To  hurt  them  back."  "  You  kill  a  person  if  he 
does  something  to  you." 


INSTRUCTIONS  FOR  YEAR  XII  525 

Unsatisfactory:—"  To  be  mad."  "  To  kill  them."  "  To 
hate  someone  who  has  done  you  wrong." 

(c)  Charity.  Satisfactory: — "  To  give  to  the  poor." 
"  To  give  to  somebody  without  pay." 

Unsatisfactory: — "  A  place  where  poor  people  get  food 
and  things."     "  Charity  is  being  treated  good." 

(d)  Envy.  Satisfactory: — "  You  envy  someone  who  has 
something  you  want."  "It's  when  you  see  a  person  better 
off  than  you  are." 

Unsatisfactory: — "  To  hate  someone."  "  Bad  feeling 
toward  anyone." 

.  (e)  Justice.  Satisfactory: — "  To  give  people  what  they 
deserve."  "  If  one  does  something  and  gets  punished, 
that's  justice." 

Unsatisfactory: — "  It  means  to  have  peace."  "  It  is 
where  they  have  court." 

3.  The  Ball-and-field  Test  (Superior  Plan).— Procedure, 
as  in  year  VIII,  test  1. 

Scoring. — Score  3  (or  superior  plan)  is  required  for  pass- 
ing in  year  XII.     (See  scoring  card.) 

4.  Dissected  Sentences. — The  Stanford  record  booklet 
contains  the  sentences  in  convenient  form. 

It  is  not  permissible  to  substitute  written  words  or  printed 
script,  as  that  would  make  the  test  harder.  All  the  words 
should  be  printed  in  caps  in  order  that  no  clue  shall  be 
given  as  to  the  first  word  in  a  sentence.  For  a  similar  reason 
the  period  is  omitted. 

Procedure. — Say:  "Here  is  a  sentence  that  has  the  words 
all  mixed  up  so  that  they  don't  make  any  sense.  If  the  words 
were  changed  around  in  the  right  order  they  would  make  a 
good  sentence.  Look  carefully  and  see  if  you  can  tell  me  how 
the  sentence  ought  to  read.'' 

Give  the  sentences  in  the  order  in  which  they  are  listed 
in  the  record  booklet.  Do  not  tell  the  subject  to  see  how 
quickly  he  can  do  it,  because  with  this  test  any  suggestion 
of  hurrying  is  likely  to  produce  a  kind  of  mental  paralysis. 
If  the  subject  has  no  success  with  the  first  sentence  in  one 


526     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

minute,  read  it  off  correctly  for  him,  somewhat  slowly,  and 
pointing  to  each  word  as  it  is  spoken.  Then  proceed  to  the 
second  and  third,  allowing  one  minute  for  each. 

Give  no  further  help.  It  is  not  permissible,  in  case  any 
incorrect  response  is  given,  to  ask  the  subject  to  try  again, 
or  to  say:  "Are  you  sure  that  is  right?  "  "Are  you  sure  you 
have  not  left  out  any  words?  "  etc.  Instead,  maintain  ab- 
solute silence.  However,  the  subject  is  permitted  to  make 
as  many  changes  in  his  response  as  he  sees  fit,  provided  he 
makes  them  spontaneously  and  within  the  allotted  time. 
Record  the  entire  response. 

Once  in  a  great  while  the  subject  misunderstands  the 
task  and  thinks  the  only  requirements  is  to  use  all  the 
words  given,  and  that  it  is  permitted  to  add  as  many  other 
words  as  he  likes.  It  is  then  necessary  to  repeat  the  instruc- 
tions and  to  allow  a  new  trial. 

Scoring. — Tioo  sentences  out  of  three  must  he  correctly 
given  within  the  minute  allotted  to  each.  It  is  understood, 
of  course,  that  if  the  first  sentence  has  to  be  read 
for  the  subject,  both  the  other  responses  must  be  given 
correctly. 

A  sentence  is  not  counted  correct  if  a  single  word  is 
omitted,  altered,  or  inserted,  or  if  the  order  given  fails  to 
make  perfect  sense. 

Certain  responses  are  not  absolutely  incorrect,  but  are 
objectionable  as  regards  sentence  structure,  or  else  fail  to 
give  the  exact  meaning  intended.  These  are  given  half 
credit.  Full  credit  on  one,  and  half  credit  on  each  of  the 
other  two,  is  satisfactory. 

(a)  Satisfactory: — "  We  started  for  the  country  at  an 
early  hour."  "  At  an  early  hour  we  started  for  the  country." 
"  We  started  at  an  early  hour  for  the  country." 

Unsatisfactory: — "  We  started  early  at  an  hour  for  the 
country."  "  Early  at  an  hour  we  started  for  the  country." 
"  We  started  early  for  the  country." 

Half  credit: — "  For  the  country  at  an  early  hour  we 
started."     "  For  the  country  we  started  at  an  early  hour." 


INSTRUCTIONS  FOR  YEAR  XII  527 

(&)  Satisfactory: — "  I  asked  my  teacher  to  correct  my 
paper." 

Unsatisfactory: — "  My  teacher  asked  to  correct  my 
paper."     "  To  correct  my  paper  I  asked  my  teacher." 

Half  credit: — "  My  teacher  I  asked  to  correct  my  paper." 

(c)  Satisfactory: — "  A  good  dog  defends  his  master 
bravely."     "  A  good  dog  bravely  defends  his  master." 

Unsatisfactory: — "  A  dog  defends  his  master  bravely." 
"A  bravely  dog  defends  his  master."  "A  good  dog  defends  his 
bravely  master."     "  A  good  brave  dog  defends  his  master." 

Half  credit: — "  A  dog  defends  his  good  master  bravely." 
"  A  dog  bravely  defends  his  good  master."  "  A  good  mas- 
ter bravely  defends  his  dog." 

5.  Interpretation  of  Fables. — Procedure. — Present  the 
fables  in  the  order  in  which  they  are  given  in  the  record 
booklet.  The  method  is  to  say  to  the  subject:  "  You  know 
what  a  fable  isf  You  have  heard  fables?  "  Whatever  the 
answer,  proceed  to  explain  a  fable  as  follows:  "A  fable,  you 
know,  is  a  little  story,  and  is  meant  to  teach  us  a  lesson.  Now, 
I  am  going  to  read  a  fable  to  you.  Listen  carefully,  and  when 
I  am  through  I  will  ask  you  to  tell  me  what  lesson  the  fable 
teaches  us.  Ready;  listen."  After  reading  the  fable,  say: 
"  What  lesson  does  that  teach  usf  "  Record  the  response 
verbatim  and  proceed  with  the  next  as  follows:  "Here  is 
another.  Listen  again  and  tell  me  what  lesson  this  fable 
teaches  us,"  etc. 

As  far  as  possible,  avoid  comment  or  commendation  until 
all  the  fables  have  been  given.  If  the  first  answer  is  of  an 
inferior  type  and  we  express  too  much  satisfaction  with  it, 
we  thereby  encourage  the  subject  to  continue  in  his  error. 
On  the  other  hand,  never  express  dissatisfaction  with  a 
response,  however  absurd  or  malapropos  it  may  be.  Many 
subjects  are  anxious  to  know  how  well  they  are  doing  and 
continually  ask,  "  Did  I  get  that  one  right?  "  It  is  sufficient 
to  say,  "  You  are  getting  along  nicely,"  or  something  to 
that  effect.  Offer  no  comments,  suggestions,  or  questions 
which  might  put  the  subject  on  the  right  track.     This  much 


528     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

self-control  is  necessary  if  we  would  make  the  conditions 
of  the  test  uniform  for  all  subjects. 

The  only  occasion  when  a  supplementary  question  is 
permissible  is  in  case  of  a  response  whose  meaning  is  not 
clear.  Even  then  we  must  be  cautious  and  restrict  ourselves 
to  some  such  question  as,  "  What  do  you  mean?  "  or,  "  Ex- 
plain;  I  don't  quite  understand  what  you  mean."  The  scor- 
ing of  fables  is  somewhat  difficult  at  best,  and  this  addi- 
tional question  is  often  sufficient  to  place  the  response  very 
definitely  in  the  right  or  wrong  column. 

Scoring. — Give  score  2,  i.e.,  2  points,  for  a  correct  answer, 
and  1  for  an  answer  which  deserves  half  credit.  The  test 
is  passed  in  year  XII  if  4  points  are  earned;  that  is,  if  two 
responses  are  correct  or  if  one  is  correct  and  tv/o  deserve 
half  credit. 

Score  2  means  that  the  fable  has  been  correctly  inter- 
preted and  that  the  lesson  it  teaches  has  been  stated  in 
general  terms. 

There  are  two  types  of  responses  which  may  be  given  half 
credit.  They  include  (1)  the  interpretations  which  are 
stated  in  general  terms  and  are  fairly  plausible,  but  are 
not  exactly  correct;  and  (2)  those  which  are  perfectly  correct 
as  to  substance,  but  are  not  generalized. 

We  overlook  ordinary  faults  of  expression  and  regard 
merely  the  essential  meaning  of  this  response. 

(a)  Hercules  and  the  wagoner.  Full  credit;  score  2: — 
"  Do  not  depend  on  others."  "  It  teaches  that  we  should 
rely  upon  ourselves."  "  We  should  always  try,  even  if  it 
looks  hard  and  we  think  we  can't  do  it." 

Half  credit;  score  1: — This  is  most  often  given  for  the 
response  which  contains  the  correct  idea,  but  states  it  in 
terms  of  the  concrete  situation,  e.g.:  "  The  man  ought  to 
have  tried  himself  first."  "  Hercules  wanted  to  teach  the 
man  to  help  himself." 

Unsatisfactory ;  score  0: — "  Teaches  us  to  look  where 
we  are  going."  "  Not  to  get  stuck  in  the  mud."  "  He 
wanted  the  man  to  help  the  oxen." 


INSTRUCTIONS  FOR  YEAR  XII  529 

(6)  The  Maid  and  the  Eggs.  Full  credit;  score  2: — 
*■  Teaches  us  not  to  build  air-castles."  "  Not  to  plan  too 
far  ahead."     "  Never  make  too  many  plans." 

Half  credit;  score  1: — "  She  was  building  air-castles  and 
so  lost  her  milk."  "  To  keep  our  mind  on  what  we  are 
doing."     "  Not  to  imagine;  go  ahead  and  do  it." 

Unsatisfactory;  score  0: — "  Not  to  take  risks  like  that." 
"  To  keep  your  chickens  and  you  will  make  more  money." 
"  She  wanted  the  money." 

(c)  The  Fox  and  the  Crow.  Full  credit;  score  2: — "  It 
is  not  safe  to  believe  people  who  flatter  us." 

Half  credit;  score  1: — "The  crow  listened  to  flattery 
and  got  left."  "  Not  to  be  proud  and  let  people  think  you 
can  sing  when  you  can't."  "  Not  to  be  too  proud."  "  Not 
to  do  everything  people  tell  you." 

Unsatisfactory;  score  0: — "  To  share  your  food."  "Not 
to  listen  to  evil."  "  Never  listen  to  advice."  "  Not  to 
sing  before  you  eat."  "  Not  to  hold  a  thing  in  your  mouth; 
eat  it."  "  To  swallow  it  before  you  sing."  "  The  fox 
was  slicker  than  what  the  crow  was."  "  The  fox  wanted  the 
meat  and  just  told  the  crow  that  to  get  it." 

(d)  The  Farmer  and  the  Stork.  Full  credit;  score  2: — 
"  Teaches  us  to  keep  out  of  bad  company."  "  Birds  of  a 
feather  flock  together." 

Half  credit;  score  1: — "  The  stork  should  not  have  been 
with  the  cranes."     "  Not  to  follow  others." 

Unsatisfactory;  score  0: — "Not  to  tell  lies."  "Not  to 
give  excuses."  "  Not  to  trust  what  people  say."  "  To  tend 
to  your  own  business."  "  Taught  the  stork  to  keep  out 
of  the  man's  field."  "  Served  the  stork  right,  he  was  steal- 
ing too." 

(e)  The  Miller,  His  Son,  and  the  Donkey.  Full  credit; 
score  2: — "Don't  take  everyone's  advice."  "Don't  try 
to  do  what  everybody  tells  you."  "  Use  your  own  judg- 
ment." 

Half  credit;  score  1:^"  Don't  take  foolish  advice." 
"  They  were  fools  to  listen  to  everybody." 


530     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Unsatisfactory;  score  0: — "  To  do  what  people  tell  you." 
"  Not  to  be  cruel  to  animals."  "  That  it  is  always  better 
to  leave  things  as  they  are."  "  Not  to  try  to  carry  the  don- 
key." "  That  the  father  should  be  allowed  to  ride."  "  The 
men  were  too  heavy  for  the  donkey." 

6.  Repeating  Five  Digits  Reversed. — The  series  are 
3-1-8-7-9;  6-9^-8-2;  5-2-9-6-1. 

Procedure  and  Scoring. — Exactly  as  in  years  VII  and 
IX. 

7.  Interpretation  of  Pictures. — Procedure. — Use  the 
same  pictures  as  in  III,  1,  and  VII,  2,  and  the  additional 
picture  d.  Present  in  the  same  order.  The  formula  to 
begin  with  is  identical  with  that  in  VII,  2:  "  Tell  me  what 
this  picture  is  about.  What  is  this  a  picture  off  "  This 
formula  is  chosen  because  it  does  not  suggest  specifically 
either  description  or  interpretation,  and  is  therefore  adapted 
to  show  the  child's  spontaneous  or  natural  mode  of  apper- 
ception. However,  in  case  this  formula  fails  to  bring 
spontaneous  interpretation  for  three  of  the  four  pictures, 
we  then  return  to  those  pictures  on  which  the  subject  has 
failed  and  give  a  second  trial  with  the  formula:  '' Explain 
this  picture."  A  good  many  subjects  who  failed  to  interpret 
the  pictures  spontaneously  do  so  without  difficulty  when  the 
more  specific  formula  is  used. 

If  the  response  is  so  brief  as  to  be  difficult  to  classify, 
the  subject  should  be  urged  to  amplify  by  some  such 
injunction  as  "Go  ahead,"  or  "Explain  what  you 
mean." 

One  more  caution.  It  is  necessary  to  refrain  from  voic- 
ing a  single  word  of  commendation  or  approval  until  all 
the  pictures  have  been  responded  to.  A  moment's  thought 
will  reveal  the  absolute  necessity  of  adhering  to  this  rule. 
Often  a  subject  will  begin  by  giving  an  inferior  type  of 
response  (description,  say)  to  the  first  picture,  but  with  the 
second  picture  adjusts  better  to  the  task  and  responds  satis- 
factorily. If  in  such  a  case  the  first  (unsatisfactory)  re- 
sponse were  greeted  with  an  approving  "  That's  fine,  you 


INSTRUCTIONS  FOR  YEAR  XII  531 

are  doing  splendidly,"  the  likelihood  of  any  improvement 
taking  place  as  the  test  proceeds  would  be  greatly 
lessened. 

Scoring. — Three  pictures  out  of  four  must  be  satisfactorily 
interpreted.  "  Satisfactorily  "  means  that  the  interpreta- 
tion given  should  be  reasonably  plausible;  not  necessarily 
the  exact  one  the  artist  had  in  mind,  yet  not  absurd. 

(a)  Dutch  Home.  Satisfactory: — "  Child  has  spilled  some- 
thing and  is  getting  a  scolding."  "  The  baby  is  crying 
because  she  is  hungry  and  the  mother  has  nothing  to  give 
her."  "  It's  a  poor  family.  The  father  is  dead  and  they 
don't  have  enough  to  eat." 

Unsatisfactory: — "  The  baby  is  crying  and  the  mother  is 
looking  at  her  "  (description).  "  It's  in  Holland,  and  there's 
a  little  girl  crying,  and  a  mamma,  and  there's  a  dish  on  the 
table  "  (mainly  description).  "  The  mother  is  teaching  the 
child  to  walk  "  (absurd  interpretation). 

(b)  River  Scene.  Satisfactory: — "  I  think  it  represents 
a  honeymoon  trip."  "  It's  a  perilous  journey  and  they 
have  engaged  the  Indian  to  row  for  them." 

Unsatisfactory: — "  An  Indian  rowing  a  man  and  his  wife 
down  the  river  "  (mainly  description).  "  A  storm  at  sea  " 
(absurd  interpretation).  "  Indians  have  rescued  a  couple 
from  a  shipwreck."  "  They  have  been  up  the  river  and 
are  riding  down  the  rapids." 

(c)  Post-Office.  Satisfactory: — "  There's  something  funny 
in  the  paper  about  one  of  the  men  and  they  are  all  laughing 
about  it."  "  It's  a  bunph  of  country  politicians  reading 
the  election  news." 

Unsatisfactory: — "  It's  a  little  country  town  and  they 
are  looking  at  the  paper."  "A  man  is  reading  the  paper 
and  the  others  are  looking  on  and  laughing."  "  They  are 
laughing  about  something  in  the  newspaper." 

(d)  Colonial  Home.  Satisfactory: — "  They  are  lovers 
and  have  quarreled."  "  The  woman  is  crying  because  her 
husband  is  angry  and  leaving  her." 

Unsatisfactory: — "  The  husband  is  leaving  and  the  dog 


532     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

is  looking  at  the  lady."  '''  The  lady  is  crying  and  the  man 
is  trying  to  comfort  her."  "  They  have  lost  their  money 
and  they  are  sad  "  (gratuitous  interpretation). 

8.  Giving  Similarities  of  Three  Things. — Procedure. — 
The  procedure  is  the  same  as  in  VIII,  4,  but  with  the  follow- 
ing words:  (a)  Snake,  cow,  sparrow,  (b)  Book,  teacher, 
newspaper.  (c)  Wool,  cotton,  leather.  (d)  Knife-blade, 
penny,  piece  of  wire,  (e)  Rose,  potato,  tree.  As  before,  a 
little  tactful  urging  is  occasionally  necessary  in  order  to 
secure  a  response. 

Scoring. — Three  satisfactory  responses  out  of  five  are  neces- 
sary for  success.  Any  real  similarity  is  acceptable ,  whether 
fundamental  or  superficial,  although  the  giving  of  funda- 
mental likenesses  is  especially  symptomatic  of  good  intelli- 
gence. 

Failures  may  be  classified  under  four  heads:  (1)  Leaving 
one  of  the  words  out  of  consideration ;  (2)  giving  a  difference 
instead  of  a  similarity;  (3)  giving  a  similarity  that  is  not 
real  or  that  is  too  bizarre  or  far-fetched;  and  (4)  inability 
to  respond. 

This  test  provokes  doubtful  responses  somewhat  oftener 
than  the  earlier  test  of  giving  similarities.  Those  giving 
greatest  difficulty  are  the  indefinite  statements  like  "  All 
are  useful,"  "  All  are  made  of  the  same  material,"  etc. 
Fortunately,  in  most  of  these  cases  an  additional  question 
is  sufficient  to  determine  whether  the  subject  has  in  mind 
a  real  similarity.  Questions  suitable  for  this  purpose  are: 
"  Explain  what  you  mean,"  "  In  what  respect  are  they  all 
useful?  "  "  What  material  do  you  mean?  "  etc.  Of  course 
it  is  only  permissible  to  make  use  of  supplementary  ques- 
tions of  this  kind  when  they  are  necessary  in  order  to  clarify 
a  response  which  has  already  been  made. 

(a)  Snake,  cow,  sparrow.  Satisfactory: — "  All  are  ani- 
mals."    "  All  move  about." 

Unsatisfactory: — "  All  have  legs."  "  All  walk  on  the 
ground."  "  A  snake  crawls,  a  cow  walks,  and  a  sparrow 
flies." 


INSTRUCTIONS  FOR  YEAR  XIV  533 

(6)  Book,  teacher,  newspaper.  Satisfactory: — "  You  learn 
from  all."     "  All  help  you  get  an  education." 

Unsatisfactory: — "  All  tell  you  the  news."  "  A  teacher 
writes,  and  a  book  and  newspaper  have  writing." 

(c)  Wool,  cotton,  leather.  Satisfactory: — "  All  used  for 
clothing."     "  We  wear  them  all." 

Unsatisfactory:—"  All  grow  on  animals."  "  They  are 
pretty." 

(d)  Knife-blade,  penny,  piece  of  wire.  Satisfactory: — 
"  All  are  made  from  minerals." 

Unsatisfactory: — "All  are  made  of  steel."  "You  buy 
them  with  money."  "  One  is  sharp,  one  is  round,  and  one 
is  long." 

(e)  Rose,  potato,  tree.  Satisfactory: — "  All  grow  from  the 
ground." 

Unsatisfactory: — "  All  are  pretty."     "  All  are  valuable.'' 

Instructions  for  Year  XIV 

1.  Vocabulary:  Fifty  Definitions. — Procedure  and  Scor- 
ing, as  in  VIII,  X,  and  XII. 

2.  Induction  Test:  Finding  a  Rule. — ^Procedure. — Pro- 
vide six  sheets  of  thin  blank  paper,  say  8|  by  11  inches. 
Take  the  first  sheet,  and  telling  the  subject  to  watch  what 
you  do,  fold  it  once,  and  in  the  middle  of  the  folded  edge 
tear  out  or  cut  out  a  small  notch;  then  ask  the  subject  to 
tell  you  how  many  holes  there  will  he  in  the  paper  when  it  is 
unfolded.  The  correct  answer,  one,  is  nearly  always  given 
without  hesitation.  But  whatever  the  answer,  unfold  the 
paper  and  hold  it  up  broadside  for  the  subject's  inspection. 
Next,  take  another  sheet,  fold  it  once  as  before  and  say: 
"  Now,  when  we  folded  it  this  way  and  tore  out  a  piece,  you 
remember  it  made  one  hole  in  the  paper.  This  time  we  will 
give  the  paper  another  fold  and  see  how  many  holes  we  shall 
have."  Then  proceed  to  fold  the  paper  again,  this  time  in 
the  other  direction,  and  tear  out  a  piece  from  the  folded  side 
and  ask  how  many  holes  there  will  be  when  the  paper  is 
unfolded.     After  recordmg  the  answer,  unfold  the  paper, 


534     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

hold  it  up  before  the  subject  so  as  to  let  him  see  the  result. 
The  answer  is  often  incorrect  and  the  unfolded  sheet  is  greeted 
with  an  exclamation  of  surprise.  The  governing  principle 
is  seldom  made  out  at  this  stage  of  the  experiment.  But 
regardless  of  the  correctness  or  incorrectness  of  the  first 
and  second  answers,  proceed  with  the  third  sheet.  Fold 
it  once  and  say:  "  When  we  folded  it  this  way  there  was  one 
hole."  Then  fold  it  again  and  say:  "  And  when  we  folded 
it  this  way  there  were  two  holes."  At  this  point  fold  the 
paper  a  third  time  and  say:  "Now,  lam  folding  it  again. 
How  many  holes  will  it  have  this  time  when  I  unfold  itf  " 
Record  the  answer  and  again  unfold  the  paper  while  the 
subject  looks  on. 

Continue  in  the  same  manner  with  sheets  four,  five,  and 
six,  adding  one  fold  each  time.  In  folding  each  sheet  reca- 
pitulate the  results  with  the  previous  sheets,  saying  (with  the 
sixth,  for  example):  "  When  we  folded  it  this  way  there  was 
one  hole,  when  we  folded  it  again  there  were  two,  when  we 
folded  it  again  there  were  four,  when  we  folded  it  again  there 
were  eight,  when  we  folded  it  again  there  were  sixteen;  now, 
tell  me  how  many  holes  there  will  he  if  we  fold  it  once  more." 
In  the  recapitulation  avoid  the  expression  "  When  we  folded 
it  once,  twice,  three  times,"  etc.,  as  this  often  leads  the  sub- 
ject to  double  the  numeral  heard  instead  of  doubling  the 
number  of  holes  in  the  previously  folded  sheet.  After  the 
answer  is  given,  do  not  fail  to  unfold  the  paper  and  let  the 
subject  view  the  result. 

Scoring. — The  test  is  passed  if  the  rule  is  grasped  by  the 
time  the  sixth  sheet  is  reached;  that  is,  the  subject  may 
pass  after  five  incorrect  responses,  provided  the  sixth  is 
correct  and  the  governing  rule  can  then  be  given.  It  is 
not  permissible  to  ask  for  the  rule  until  all  six  parts  of  the 
experiment  have  been  given.  Nothing  must  be  said  which 
could  even  suggest  the  operation  of  a  rule.  Often,  however, 
the  subject  grasps  the  principle  after  two  or  three  steps  and 
gives  it  spontaneously.  In  this  case  it  is  unnecessary  to 
proceed  with  the  remaining  steps. 


INSTRUCTIONS  FOR  YEAR  XIV  535 

3.  Giving  Differences  between  a  President  and  a  King. — 
Procedure. — Say:  "  There  are  three  main  differences  between 
a  president  and  a  king;  what  are  they?  "  If  the  subject 
stops  after  one  difference  is  given,  we  urge  him  on,  if  possi- 
ble, until  three  are  given. 

Scoring. — The  three  differences  relate  to  power,  tenure, 
and  manner  of  accession.  Only  these  differences  are  con- 
sidered correct,  and  the  successful  response  must  include 
at  least  two  of  the  three.  We  disregard  crudities  of  expres- 
sion and  note  merely  whether  the  subject  has  the  essential 
idea.  As  regards  power,  for  example,  any  of  the  following 
responses  are  satisfactory:  "  The  king  is  absolute  and  the 
president  is  not."  ''  The  king  rules  by  himseK,  but  the  presi- 
dent rules  with  the  help  of  the  people."  "  Kings  can  have 
things  their  own  way  more  than  presidents  can,"  etc. 

It  may  be  objected  that  the  reverse  of  this  is  sometimes 
true,  that  the  king  of  to-day  often  has  less  power  than  the 
average  president.  Sometimes  subjects  mention  this  fact, 
and  when  they  do  we  credit  them  with  this  part  of  the  test. 
As  a  matter  of  fact,  however,  this  answer  is  seldom  given. 

Sometimes  the  subject  does  not  stop  until  he  has  given 
a  half-dozen  or  more  differences,  and  in  such  cases  the 
first  three  differences  may  be  trivial  and  some  of  the  later 
ones  essential.  The  question  then  arises  whether  we  should 
disregard  the  errors  and  pass  the  subject  on  his  later  cor- 
rect responses.  The  rule  in  such  cases  is  to  ask  the  subject 
to  pick  out  the  "  three  main  differences." 

Sometimes  accession  and  tenure  are  given  in  the  form  of 
a  single  contrast,  as:  "  The  president  is  elected,  but  the 
king  inherits  his  throne  and  rules  for  life."  This  answer 
entitles  the  subject  to  credit  for  both  accession  and  tenure, 
the  contrast  as  regards  tenure  being  plainly  implied. 

4.  Problem  Questions. — Procedure. — Say  to  the  subject: 
"Listen,  and  see  if  you  can  understand  what  I  read."  Then 
read  the  three  problems,  rather  slowly  and  with  expression, 
pausing  after  each  long  enough  for  the  subject  to  find  an 
answer. 


536     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Do  not  ask  questions  calculated  to  draw  out  the  correct 
response,  but  wait  in  silence  for  the  subject's  spontaneous 
answer.  It  is  permissible,  however,  to  re-read  the  passage 
if  the  subject  requests  it. 

Scoring. — Two  responses  out  of  three  must  he  satisfactory. 

(a)  What  the  man  saw  hanging.  Satisfactory: — The  only- 
correct  answer  for  the  first  is  "  A  man  who  had  hung  himself  " 
(or  who  had  committed  suicide,  been  hanged,  etc.).  We 
may  also  pass  the  following  answer:  "  Dead  branches  that 
looked  like  a  man  hanging." 

Unsatisfactory: — There  is  an  endless  variety  of  failures: 
"A  snake,"   ''A  monkey,"   "A  robber,"  or  "A  tramp." 

(&)  My  neighbor.  Satisfactory: — The  expected  answer 
is  "  A  death,"  "  Someone  has  died,"  etc.  We  must  always 
check  up  this  response,  however,  by  asking  what  the  lawyer 
came  for,  and  this  must  also  be  answered  correctly.  "  A 
murder.  The  doctor  came  to  examine  the  body,  the  lawyer 
to  get  evidence,  and  the  preacher  to  preach  at  the  funeral." 

If  an  incorrect  answer  is  first  given  and  then  corrected,  the 
correction  is  accepted. 

Unsatisfactory: — The  failures  again  are  quite  varied,  but 
are  most  frequently  due  to  failure  to  understand  the  lawyer's 
mission.  "  A  baby  born."  "  An  entertainment."  "  Some 
friends  came  to  chat."  "  Somebody  was  sick;  the  lawyer 
wanted  his  money  and  the  minister  came  to  see  how  he  was." 

(c)  What  the  man  was  riding  on. — The  only  correct  re- 
sponse is  "  Bicycle."  The  most  common  error  is  horse 
(or  donkey),  accounting  for  48  out  of  71  tabulated  failures. 
Vehicles,  like  wagon,  huggy,  automobile,  or  street  car,  were 
mentioned  in  14  out  of  71  failures. 

5.  Arithmetical  Reasoning. — Procedure. — The  problems 
are  shown  one  at  a  time  to  the  subject,  who  reads  each 
problem  aloud  and  (with  the  printed  problem  still  before 
him)  finds  the  answer  without  the  use  of  pencil  or  paper. 

Only  one  minute  is  allowed  for  each  problem,  but  nothing 
is  said  about  hurr5dng.  While  one  problem  is  being  solved 
the  others  should  be  hidden  from  view.     It  is  not  permissible. 


INSTRUCTIONS  FOR  YEAR  XIV  537 

if  the  subject  gives  an  incorrect  answer,  to  ask  him  to  solve 
the  problem  again.  The  following  exception,  however,  is 
made  to  this  rule:  if  the  answer  given  to  the  third  problem 
indicates  that  the  word  yard  has  been  read  as  feet,  the  sub- 
ject is  asked  to  read  the  problem  through  again  carefully 
(aloud)  and  to  tell  how  he  solved  it.  No  further  help  of  any- 
kind  may  be  given. 

Scoring. — Tico  of  the  three  problems  must  be  solved  cor- 
rectly within  the  minute  allotted  to  each.  No  credit  is 
allowed  for  correct  method  if  the  answer  is  wrong. 

6.  Reversing  Hands  of  Clock. — Procedure. — Say  to  the 
subject:  "  Suppose  it  is  six-twenty-two  o'clock,  that  is,  twenty- 
two  minutes  after  six;  can  you  see  in  your  mind  where  the  large 
hand  would  he,  and  where  the  small  hand  would  hef  "  Subjects 
of  twelve-  to  fourteen-year  intelligence  practically  always 
answer  this  in  the  affirmative.  Then  continue:  "Now, 
suppose  the  two  hands  of  the  clock  were  to  trade  places,  so 
that  the  large  hand  takes  the  place  where  the  small  hand  was, 
and  the  small  hand  takes  the  place  where  the  large  hand  was. 
What  time  woidd  it  then  he?  " 

Repeat  the  test  with  the  hands  at  8.10  (10  minutes  after 
8),  and  again  with  the  hands  at  2.46  (14  minutes  before  3). 

The  subject  is  not  allowed  to  look  at  a  clock  or  watch, 
or  to  aid  himself  by  drawing,  but  must  work  out  the  prob- 
lem mentally.  As  a  rule  the  answer  is  given  within  a  few 
seconds  or  not  at  all.  If  an  answer  is  not  forthcoming  within 
two  minutes  the  score  is  failure. 

Scoring. — The  test  is  passed  if  two  of  the  three  problems 
are  solved  within  the  following  range  of  accuracy:  the  first 
solution  is  considered  correct  if  the  answer  falls  between 
4.30  and  4.35,  inclusive;  the  second  if  the  answer  falls  be- 
tween 1.40  and  1.45,  and  the  third  if  the  answer  falls  be- 
tween 9.10  and  9.15. 

Alternative  Test:  Repeating  Seven  Digits. — This  time, 
as  in  year  X,  only  two  series  are  given,  one  of  which  must 
be  repeated  without  error.  The  two  series  are:  2-1-8-3-4- 
3-9  and  9-7-2-8-4-7-5.     Note  that  in  none  of  the  tests  of 


538     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

repeating  digits  is  it  permissible  to  warn  the  subject  of  the 
number  to  be  given. 

Instructions  for  "  Average  Adult  " 

1.  Vocabulary:  Sixty-five  Definitions. — ^Procedure  and 
Scoring,  as  in  previous  vocabulary  tests. 

2.  Interpretation  of  Fables  (Score  8). — Procedure. — 
As  in  year  XII,  test  6.     Use  the  same  fables. 

Scoring. — The  method  of  scoring  is  the  same  as  for  XII, 
but  the  total  score  must  be  8  points  to  satisfy  the  require- 
ments at  this  level. 

3.  Differences  between  Abstract  Terms. — Procedure. — 
Say:  What  is  the  difference  between:  (a)  Laziness  and  idle- 
ness? (6)  Evolution  and  revolutionf  (c)  Poverty  and  misery? 
(d)  Character  and  reputation? 

Scoring. — Three  correct  contrasting  definitions  out  of  four 
are  necessary  for  a  pass.  It  is  not  sufiicient  merely  to 
give  a  correct  meaning  for  each  word  of  a  pair;  the  subject 
must  point  out  a  difference  between  the  two  words  so  as  to 
make  a  real  contrast.  For  example,  if  the  subject  defines 
evolution  as  a  "  growth  "  or  "  gradual  change,"  and  revolu- 
tion as  the  running  of  a  wheel  on  its  axis,  the  experimenter 
should  say:  "  Yes,  hut  I  want  you  to  tell  me  the  difference 
between  evolution  and  revolution."  If  the  contrast  is  not  then 
forthcoming  the  response  is  marked  minus.  The  following 
are  sample  definitions  which  may  be  considered  acceptable: 

(a)  Laziness  and  idleness. — "  Laziness  means  you  don't 
want  to  work;  idleness  means  you  are  not  doing  anything 
just  now."  "  Laziness  comes  from  within ;  idleness  may  be 
forced  upon  one."  The  essential  contrast,  accordingly, 
is  that  laziness  refers  to  unwillingness  to  work;  idleness  to  the 
mere  fact  of  inactivity.  This  contrast  must  be  expressed, 
however  clumsily. 

(6)  Evolution  and  revolution.  '*  Evolution  is  a  gradual 
change;  revolution  is  a  sudden  change."  "  Evolution  is 
natural    development;     revolution    is    sudden    upheaval." 


INSTRUCTIONS  FOR  "  AVERAGE  ADULT  "  539 

The  essential  distinction,  accordingly,  is  that  evolution 
means  a  gradual,  natural,  or  slow  change,  while  revolution 
means  a  sudden,  forced,  or  violent  change.  Non-contrasting 
definitions,  even  when  the  individual  terms  are  defined  cor- 
rectly, are  not  satisfactor3^ 

(c)  Poverty  and  misery.  '' Poverty  is  when  you  are  poor; 
misery  means  suffering."  "  Poverty  comes  from  lack  of 
money;  misery,  from  lack  of  happiness  or  comfort." 

{d)  Character  and  reputation.  "  Character  is  what  you 
are;  reputation  is  what  people  say  about  you."  "  A  man  has 
a  good  character  if  he  would  not  do  evil;  but  a  man  may  have 
a  good  reputation  and  still  have  a  bad  character." 

A  little  practice  and  a  good  deal  of  discrimination  are 
necessary  for  the  correct  grading  of  responses  to  this  test. 
Subjects  are  often  so  clumsy  in  expression  that  their  re- 
sponses are  anything  but  clear.  It  is  then  necessary  to  ask 
them  to  explain  what  they  mean.  Further  questioning, 
however,  is  not  permissible.  For  uniformity  in  scoring  it  is 
necessary  to  bear  in  mind  that  the  definitions  given  must, 
in  order  to  be  satisfactory,  express  the  essential  distinction 
between  the  two  words. 

4.  Problem  of  the  Enclosed  Boxes. — Procedure. — Show 
the  subject  a  cardboard  box  about  one  inch  on  a  side. 
Say:  "  You  see  this  box;  it  has  two  smaller  boxes  inside  of 
it  and  each  of  the  smaller  boxes  contains  a  little  tiny  box.  How 
many  boxes  are  there  altogether,  counting  the  big  one?  "  To 
be  sure  that  the  subject  understands  repeat  the  statement  of 
the  problem:  "First  the  large  box,  then  two  smaller  ones, 
and  each  of  the  smaller  ones  contains  a  little  tiny  box.'' 

Record  the  response,  and,  showing  another  box,  say: 
"  This  box  has  two  smaller  boxes  inside,  and  each  of  the 
smaller  boxes  contains  two  tiny  boxes.  How  many  altogether? 
Remember,  first  the  large  box,  then  two  smaller  ones,  and  each 
smaller  one  contains  two  tiny  boxes." 

The  third  problem,  which  is  given  in  the  same  way, 
states  that  there  are  three  smaller  boxes,  each  of  which  con- 
tains three  tiny  boxes. 


540     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

In  the  fourth  problem  there  are  four  smaller  boxes,  each 
containing. /owr  tiny  boxes. 

The  problem  must  be  given  orally,  and  the  solution  must 
be  found  without  the  aid  of  pencil  or  paper.  Only  one  half- 
minute  is  allowed  for  each  problem.  Note  that  each  prob- 
lem is  stated  twice. 

A  correction  is  permitted,  provided  it  is  offered  spon- 
taneously and  does  not  seem  to  be  the  result  of  guessing. 
Guessing  can  be  checked  up  by  asking  the  subject  to  ex- 
plain the  solution. 

Scoring. — Three  of  the  four  problems  must  be  solved  cor- 
rectly within  the  half-minute  allotted  to  each. 

5.  Repeating  Six  Digits  Reversed. — The  series  used  are: 
4-7-1-9-5-2;  5-8-3-2-9-4;  and  7-5-2-6-3-8. 

Procedure  and  Scoring,  as  in  year  VII,  alternative  2. 

6.  Using  a.  Code. — ^Procedure. — Show  the  subject  the 
code  given  on  the  printed  card.  Say:  "  See  these  diagrams 
here.  Look  and  you  will  see  that  they  contain  all  the 
letters  of  the  alphabet.  Now,  examine  the  arrangement  of 
the  letters.  They  go  (pointing)  a  b  c,  d  e  f,  g  h  i,  j  k  I, 
m  n  0,  p  q  r,  s  t  u  V,  w  X  y  z.  You  see  the  letters  in  the  first 
two  diagrams  are  arranged  in  the  up-and-down  order  (pointing 
again),  and  the  letters  in. the  other  two  diagrams  run  in  just  the 
opposite  way  from  the  hands  of  a  clock  (pointing).  Look 
again  and  you  will  see  that  the  second  diagram  is  drawn  just 
like  the  first,  except  that  each  letter  has  a  dot  with  it,  and  that 
the  last  diagram  is  like  the  third  except-  that  here,  also,  each 
letter  has  a  dot.  Now,  all  of  this  represents  a  code;  that  is,  a 
secret  language.  It  is  a  real  code,  one  that  was  used  in  the 
Civil  War  for  sending  secret  messages.  This  is  the  way  it 
works:  we  draw  the  lines  which  hold  a  letter,  but  leave  out  the 
letter.  Here,  for  example,  is  the  way  we  would  write  '  spy.  '  " 
Then  write  the  word  spy,  pointing  out  carefully  where  each 
letter  comes  from,  and  emphasizing  the  fact  that  the  dot 
must  be  used  in  addition  to  the  lines  in  writing  any  letter 
in  the  second  or  the  fourth  diagram.  Illustrate  also  with 
war. 


INSTRUCTIONS  FOR  "  AVERAGE  ADULT  "  541 

Then  add:  "/  am  going  to  have  you  write  something  for 
me;  remember  now,  how  the  letters  go,  first  (pointing,  as  before) 
ah  c,  d  ef,  g  h  i,  then  j  kl,  m  n  o,  p  qr,  then  stuv,  then 
wxy  z.  And  don't  forget  the  dots  for  the  letters  in  this  diagram 
and  this  one  "  (pointing).  At  this  point,  take  away  the  dia- 
grams and'  tell  the  subject  to  write  the  words  come  quickly. 
Say  nothing  about  hurrying. 

The  subject  is  given  a  pencil,  but  is  allowed  to  draw  only 
the  symbols  for  the  words  come  quickly.  He  is  not  permitted 
to  reproduce  the  entire  code  and  then  to  copy  the  code  let- 
ters from  his  reproduction. 

Scoring. — The  test  is  passed  if  the  words  are  written  in 
six  minutes  and  withoid  more  than  two  errors.  Omission  of 
a  dot  counts  as  only  a  half  error. 

Alternative  Test  1 :  Repeating  Twenty-eight  Syllables. — 
Procedure. — Exactly  as  in  VI,  6.  Emphasize  that  the 
sentence  must  be  repeated  without  a  single  change  of  any 
sort.     Get  attention  before  giving  each  sentence. 

Scoring. — Passed  if  one  sentence  is  repeated  without  a  single 
error.  In  VI  and  X  we  scored  the  response  as  satisfactory 
if  one  sentence  was  repeated  without  error,  or  if  two  were 
repeated  vaih.  not  more  than  one  error  each. 

Alternative  Test  2:  Comprehension  cf  Physical  Rela- 
tions.— (a)  Problem  regarding  the  path  of  a  cannon  hall. 

Procedure. — Draw  on  a  piece  of  paper  a  horizontal  Hne 
6  or  8  inches  long.  Above  it,  an  inch  or  two,  draw  a  short 
horizontal  line  about  an  inch  long  and  parallel  to  the  first. 
Tell  the  subject  that  the  long  line  represents  the  perfectly 
level  ground  of  a  field,  and  that  the  short  line  represents 
a  cannon.  Explain  that  the  cannon  is  ''  painted  horizon- 
tally {on  a  level)  and  is  fired  across  this  perfectly  level  field." 
After  it  is  clear  that  these  conditions  of  the  problem  are 
comprehended,  we  add:  ''Now,  suppose  that  this  cannon 
is  fired  off  and  that  the  hall  comes  to  the  ground  at  this 
point  here  (pointing  to  the  farther  end  of  the  line  which 
represents  the  field).  Take  this  pencil  and  draw  a  line 
which  will  show  what    path  the  cannon  hall  will  take  from 


542     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

the  time  it  leaves  the  mouth  of  the  cannon  till  it  strikes  the 
ground.^' 

Scoring. — There  are  four  types  of  response :  (1)  A  straight 
diagonal  Une  is  drawn  from  the  cannon's  mouth  to  the  point 
where  the  ball  strikes.  (2)  A  straight  Une  is  drawn  from  the 
cannon's  mouth  running  horizontally  until  almost  directly 
over  the  goal,  at  which  point  the  hne  drops  almost  or  quite 
vertically.  (3)  The  path  from  the  cannon's  mouth  first 
rises  considerably  from  the  horizontal,  at  an  angle  perhaps 
of  between  ten  to  forty-five  degrees,  and  finally  describes 
a  gradual  curve  downward  to  the  goal.  (4)  The  fine  be- 
gins almost  on  a  level  and  drops  more  rapidly  toward  the 
end  of  its  course. 

Only  the  last  is  satisfactory.  Of  course,  nothing  like  a 
mathematically  accurate  solution  of  the  problem  is  expected. 
It  is  sufficient  if  the  response  belongs  to  the  fourth  type 
above  instead  of  being  absurd,  as  the  other  types  described 
are.  Anyone  who  has  ever  thrown  stones  should  have  the 
data  for  such  an  approximate  solution.  Not  a  day  of  school- 
ing is  necessary. 

(6)  Problem  as  to  the  weight  of  a  fish  in  water. 

Procedure. — Say  to  the  subject:  "  You  know,  of  course, 
that  water  holds  up  a  fish  that  is  placed  in  it.  Well,  here  is  a 
problem.  Suppose  we  have  a  bucket  which  is  partly  full  of 
water.  We  place  the  bucket  on  the  scales  and  find  that  with 
the  water  in  it  it  weighs  exactly  45  pounds.  Then  we  put  a 
5-pound  fish  into  the  bucket  of  water.  Now,  what  will  the 
whole  thing  weigh?  " 

Scoring. — Many  subjects  even  as  low  as  nine-  or  ten- 
year  intelligence  will  answer  promptly,  "  Why,  45  pounds  and 
5  pounds  makes  50  pounds,  of  course."  But  this  is  not  suf- 
ficient. We  proceed  to  ask,  with  serious  demeanor:  "How 
can  this  be  correct,  since  the  water  itself  holds  up  the  fish?  " 
The  young  subject  who  has  answered  so  ghbly  now  laughs 
sheepishly  and  apologizes  for  his  error,  saying  that  he 
answered  without  thinking,  etc.  This  response  is  scored 
failure  without  further  questioning. 


INSTRUCTIONS  FOR  "  AVERAGE  ADULT  "  543 

Others  subjects,  mostly  above  the  fourteen-year  level, 
adhere  to  the  answer  "  50  pounds,"  however  strongly  we 
urge  the  argument  about  the  water  holding  up  the  fish. 
In  response  to  our  question,  "  Hoiv  can  that  be  the  case?  " 
it  is  sufficient  if  the  subject  replies  that  "  The  weight  is 
there  just  the  same;  the  scales  have  to  hold  up  the  bucket 
and  the  bucket  has  to  hold  up  the  water,"  or  words  to  that 
effect.  Only  some  such  response  as  this  is  satisfactory.  If 
the  subject  keeps  changing  his  answer  or  says  that  he  thinks 
the  weight  would  be  50  pounds,  but  is  not  certain,  the  score 
is  failure. 

(c)  Difficulty  of  hitting  a  distant  mark: 

Procedure. — Say  to  the  subject:  "  You  know,  do  you  not, 
what  it  means  when  they  say  a  gun  '  carries  100  yards  ^f 
It  means  that  the  bullet  goes  that  far  before  it  drops  to  amount 
to  a?iything."  All  boys  and  most  girls  more  than  a  dozen 
3-ears  old  understand  this  readily.  If  the  subject  does  not 
understand,  we  explain  again  what  it  means  for  a  gun  "  to 
carry  "  a  given  distance.  When  this  part  is  clear,  we  pro- 
ceed as  follows:  "Now,  suppose  a  man  is  shooting  at  a 
mark  about  the  size  of  a  quart  can.  His  rifle  carries 
perfectly  inore  than  100  yards.  With  such  a  -gun  is  it 
any  harder  to  hit  the  mark  at  100  yards  than  it  is  at  50 
yards?  "  After  the  response  is  given,  we  ask  the  subject  to 
explain. 

Scoring. — Simply  to  say  that  it  would  be  easier  at  50 
j^ards  is  not  sufficient,  nor  can  we  pass  the  response  which 
merely  states  that  it  is  "  easier  to  aim  "  at  50  yards.  The 
correct  principle  must  be  given,  one  which  shows  the  sub- 
ject has  appreciated  the  fact  that  a  small  deviation  from 
the  "  bull's-eye "  at  50  yards,  due  to  incorrect  aim, 
becomes  a  larger  deviation  at  100  yards.  However, 
the  subject  is  not  required  to  know  that  the  deviation 
at  100  yards  is  exactly  twice  as  great  as  at  50  yards.  A 
certain  amoimt  of  questioning  is  often  necessary  before 
we  can  decide  whether  the  subject  has  the  correct  principle 
in  mind. 


544     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

Scoring  the  Entire  Test. — Two  of  the  three  problems  must 
be  solved  in  such  a  way  as  to  satisfy  the  requirements 
above  set  forth. 

Instructions  for  "  Superior  Adult  " 

1.  Vocabulary :  Seventy-five  Definitions. — Procedure  and 
Scoring,  as  in  previous  vocabulary  tests. 

2.  Paper-cutting  Test. — Procedure. — Take  a  piece  of 
paper  about  6  inches  square  and  say:  "  Watch  carefully 
what  I  do.  See,  I  fold  the  paper  this  way  (folding  it  once 
over  in  the  middle),  then  I  fold  it  this  way  (folding  it  again 
in  the  middle,  but  at  right  angles  to  the  first  fold).  Now 
I  will  cut  out  a  notch  right  here  "  (indicating).  At  this  point 
take  scissors  and  cut  out  a  small  notch  from  the  middle  of 
the  side  which  presents  but  one  edge.  Throw  the  fragment 
which  has  been  cut  out  into  the  waste-basket  or  under  the 
table.  Leave  the  folded  paper  exposed  to  view,  but  pressed 
flat  against  the  table.  Then  give  the  subject  a  pencil  and  a 
second  sheet  of  paper  like  the  one  already  used  and  say: 
"Take  this  piece  of  paper  and  make  a  drawing  to  show  how 
the  other  sheet  of  paper  would  look  if  it  were  unfolded.  Draw 
lines  to  show  the  creases  in  the  paper  and  show  what  residts 
from  the  cutting. '' 

The  subject  is  not  permitted  to  fold  the  second  sheet, 
but  must  solve  the  problem  by  the  imagination  unaided. 

Note  that  we  do  not  say,  "Draw  the  holes/'  as  this  would 
inform  the  subject  that  more  than  one  hole  is  expected. 

Scoring. — The  test  is  passed  if  the  creases  in  the  paper  are 
properly  represented,  if  the  holes  are  drawn  in  the  correct 
number,  and  if  they  are  located  correctly,  that  is,  both  on  the 
same  crease  and  each  about  halfway  between  the  center  of 
the  paper  and  the  side.     The  shape  of  the  holes  is  disregarded. 

Failure  may  be  due  to  error  as  regards  the  creases  or 
the  number  and  location  of  the  holes,  or  it  may  involve  any 
combination  of  the  above  errors. 

3.  Repeating  Eight  Digits. — Procedure  and  Scoring, 
the   same   as   in   previous  tests    with    digits.     The    series 


INSTRUCTIONS  FOR  "  SUPERIOR  ADULT  "  545 

used  are:    7-2-5-3-4-8-9-6;  4-9-8-5-3-7-6-2;   and  8-3-7- 
9-5^-8-2. 

Guard  against  rhythm  and  grouping  in  reading  the  digits 
and  do  not  give  warning  as  to  the  number  to  be  given. 

4.  Repeating  Thoughts  of  Passage. — ^Procedure. —  Say 
"/  am  going  to  read  a  little  selection  of  about  six  or  eight  lines. 
When  I  am  through  I  will  ask  you  to  repeat  as  much  of  it  as 
you  can.  It  doesn't  make  any  difference  whether  you  remember 
the  exact  words  or  not,  but  you  must  listen  carefully  so  that 
you  can  tell  me  everything  it  says."  Then  read  the  selections, 
pausing  after  each  for  the  subject's  report,  which  should  be 
recorded  verbatim. 

Sometimes  the  subject  hesitates  to  begin,  thinking,  in 
spite  of  our  wording  of  the  instructions,  that  a  perfect 
reproduction  is  expected.  Others  fall  into  the  opposite 
misunderstanding  and  think  that  they  are  prohibited  from 
using  the  words  of  the  text  and  must  give  the  thought 
entirely  in  their  own  language.  In  cases  of  hesitation  we 
should  urge  the  subject  a  little  and  remind  him  that  he  is 
to  express  the  thought  of  the  selection  in  whatever  way  he 
prefers;  that  the  main  thing  is  to  tell  what  the  selection  says. 

Scoring. — The  test  is  passed  if  the  subject  is  able  to  re- 
peat in  reasonably  consecutive  order  the  main  thoughts  of 
at  least  one  of  the  selections.  Neither  elegance  of  expression 
nor  verbatim  repetition  is  expected.  We  merely  want  to 
know  whether  the  leading  thoughts  in  the  selection  have 
been  grasped  and  remembered. 

5.  Repeating  Seven  Digits  Reversed. — Procedure  and 
Scoring,  the  same  as  in  previous  tests  of  this  kind.  The 
series  are:  4-1-6-2-5-9-3;  3-8-2-6-4-7-5;  and  9-4-5-2- 
8-3-7.'' 

6.  Ingenuity  Test. — ^Procedure. — Problem  a  is  stated  as 
follows:  A  mother  sent  her  boy  to  the  river  and  told  him  to 
bring  back  exactly  7  pints  of  water.  She  gave  him  a  S-pint 
vessel  and  a  5-pint  vessel.  Shoiv  me  how  the  boy  can  measure 
out  exactly  7  pints  of  water,  using  nothing  but  these  two  vessels 
and  not  guessing  at  the  amount.      You  should  begin  by  filling 


546     STANFORD  REVISION  OF  BINET-SIMON  SCALE 

the  5-pint  vessel  first.  Remember,  you  have  a  S-pint  vessel  and 
a  5-pint  vessel  and  you  must  bring  back  exactly  7  pints. 

The  problem  is  given  orally,  but  may  be  repeated  if 
necessary. 

The  subject  is  not  allowed  pencil  or  paper  and  is  requested 
to  give  his  solution  orally  as  he  works  it  out.  It  is  then 
possible  to  make  a  complete  record  of  the  method  employed. 

The  subject  is  likely  to  resort  to  some  such  method  as 
to  "  fill  the  3-pint  vessel  two  thirds  full,"  or,  "  I  would  mark 
the  inside  of  the  5-pint  vessel  so  as  to  show  where  4  pints 
come  to,''  etc.  We  inform  the  subject  that  such  a  method 
is  not  allowable;  that  this  would  be  guessing,  since  he  could 
not  be  sure  when  the  3-pint  vessel  was  two  thirds  full  (or 
whether  he  had  marked  off  his  5-pint  vessel  accurately). 
Tell  him  he  must  measure  out  the  water  without  any  guess- 
work.    Explain  also,  that  it  is  a  fair  problem,  not  a  "  catch." 

Say  nothing  about  pouring  from  one  vessel  to  another, 
but  if  the  subject  asks  whether  this  is  permissible  the  answer 
is  "  yes." 

The  time  limit  for  each  problem  is  five  minutes.  If  the 
subject  fails  on  the  first  problem,  we  explain  the  solution 
in  full  and  then  proceed  to  the  next. 

The  second  problem  is  like  the  first,  except  that  a  5-pint 
vessel  and  a  7-pint  vessel  are  given,  to  get  8  pints,  the  sub- 
ject being  told  to  begin  by  filling  the  5-pint  vessel. 

In  the  third  problem  4  and  9  are  given,  to  get  7,  the 
instruction  being  to  "  begin  by  filling  the  4-pint  vessel." 

Note  that  in  each  problem  we  instruct  the  subject  how 
to  begin.  This  is  necessary  in  order  to  secure  uniformity 
of  conditions.  It  is  possible  to  solve  all  of  the  problems  by 
beginning  with  either  of  the  two  vessels,  but  the  solution 
is  made  very  much  more  difficult  if  we  begin  in  the  direc- 
tion opposite  from  that  recommended. 

Give  no  further  aid.  It  is  necessary  to  refrain  from  com- 
ment of  every  kind. 

Scoring. — Two  of  the  three  problems  must  be  solved  cor- 
rectly within  five  minutes  allotted  to  each. 


APPENDIX  VI 

FREE  ASSOCIATION  TEST  (KENT-ROSANOFF)i 

Instructions. — One  uses  a  sheet  with  the  stimulus  words 
printed  on  it  and  with  space  opposite  each  stimulus  word  for 
the  reaction.^  In  a  room  reasonably  free  from  distracting 
influences  the  subject  is  seated  at  a  distance  from  the  experi- 
menter so  as  to  be  unable  to  see  either  the  printed  stimulus 
words  or  the  reactions  as  they  are  recorded.  He  is  instructed 
to  respond  to  each  stimulus  word  with  the  first  word  that 
comes  to  his  mind  other  than  the  stimulus  word  itself  or  a 
mere  different  grammatical  form  of  it,  to  respond  with  one 
word  only  and  not  with  a  compound  word  or  a  sentence  or 
phrase.  A  few  stimulus  words  not  on  the  list  may  be  given 
for  preliminary  practice,  the  reactions  not  being  recorded; 
and  when  it  appears  that  the  subject  understands  the  in- 
structions the  test  may  be  begun.  Should  the  subject  in  the 
course  of  the  test  give  an  unacceptable  reaction,  it  is  not  put 

1  G.  H.  Kent  and  A.  J.  Rosanoff.  A  Study  of  Association  in  Insanity. 
Amer.  Joura.  of  Insanity,  July  and  Oct.,  1910. — R.  S.  Woodworth  and 
F.  L.  Wells.  Association  Tests.  Psychol.  Monogr-.,  No.  57,  1911.— 
F.  L.  Wells.  The  Question  of  Association  Types.  Psychol.  Review, 
July,  1912. — F.  C.  Eastman  and  A.  J.  Rosanoff.  Association  in  Feeble- 
Minded  and  Delinquent  Children.  Amer.  Journ.  of  Ins.,  July,  1912. — ■ 
Isabel  R.  Rosanoff  and  A.  J.  Rosanoff.  A  Study  of  Association  in 
Children.  Psychol.  Review,  Jan.,  1913. — E.  K.  Strong,  Jr.  A  Compari- 
son between  Experimental  Data  and  Clinical  Results  in  Manic-Depressive 
Insanity.  Amer.  Journ.  of  Psychol.,  Jan.,  1913. — Margaret  Otis.  A 
Study  of  Association  in  Defectives.  .Journ.  of  Educ.  Psychol.,  May, 
1915. — Ida  Mitchell,  Isabel  R.  Rosanoff,  and  A.  J.  Rosanoff.  A  Study 
of  Association  in  Negro  Children.     Psychol.  Review,  Sept.,  1919. 

2  Printed  forms  for  this  test  may  be  purchased  in  packages  of  25  from 
The  Morningside  Press,  417  West  118th  Street,  New  York. 

547 


548  FREE  ASSOCIATION  TEST 

down,  but  the  pertinent  instruction  is  repeated,  the  test 
continued,  and  at  the  end  all  the  stimulus  words  thus  im- 
properly reacted  to  and  therefore  remaining  without  a  re- 
corded reaction  are  given  over  again. 

In  cases  in  which  it  is  desired  to  use  the  association 
test  for  the  purpose  of  detecting  pathogenic  subconscious 
ideas  or  complexes  that  may  be  suspected  to  exist,  the 
examiner's  familiarity  with  the  case  will  suggest  to  him 
special  stimulus  words  adapted  to  the  particular  case; 
these  stimulus  words  may  be  given  together  with  those 
regularly  employed,  being  introduced,  say,  after  every  fifth 
or  every  tenth  one.  In  such  cases  it  is  also  advisable  to 
record  in  each  instance  the  reaction  time  in  fifths  of  a  second, 
taken  by  means  of  a  stop  watch;  subconscious  ideas  or 
complexes  are  said  to  be  indicated  either  by  abnormal 
types  of  reaction  or  by  instances  of  reaction  time  much 
above  the  average  for  the  individual. 

Classification  of  ReactionSo — This  test  has  been  applied 
to  one  thousand  normal  subjects,  and  all  reactions  thus 
obtained  arranged  in  frequency  tables  for  all  the  stimulus 
words.     These  frequency  tables  are  reprinted  below.^ 

In  the  examination  of  a  test  record  obtained  by  this 
method  the  first  step  is  to  compare  it  with  the  frequency 
tables  and  thereby  distinguish  the  common  reactions,  which 
are  to  be  found  in  the  tables  and  which  are  for  the  most 
part  normal,  from  individual  reactions,  which  are  not  to  be 
found  in  the  tables  and  which  include  the  great  majority 
of  those  that  are  of  pathological  significance. 

For  the  sake  of  accuracy,  any  reaction  word  which  is 
not  found  in  the  table  in  its  identical  form,  but  which  is  a 
grammatical  variant  of  a  word  found  there,  is  classed  as 
doubtful. 

From  amongst  both  common  and  individual  reactions  a 
fairly  definite  group  can  be  separated  out,  the  non-specific 

1  Similar  tables  have  been  compiled  for  children:  H.  Woodrow  and 
F.  Lowell.  Children's  Association  Frequency  Tables.  Psychological 
Monographs,  No.  97,  Princeton,  N.  J.,  1916. 


CLASSIFICATION  OF  REACTIONS  549 

reactions.  In  this  group  are  placed  words  which  are  so 
widely  applicable  as  to  serve  as  more  or  less  appropriate 
reactions  to  almost  any  of  the  stimulus  words.  In  the 
standardized  procedure  any  of  the  following  words,  occurring 
as  a  response  to  any  stimulus  word,  is  classed  as  non-specific : 
ojrticle,  articles,  had,  beautiful,  beauty,  fine,  good,  goodness, 
great,  happiness,  happy,  large,  man,  necessary,  necessity,  nice, 
object  {noun),  people,  person,  pleasant,  pleasantness,  pleasing, 
pleasure,  pretty,  small,  thinking,  thought,  thoughts,  unneces- 
sary, unpleasant,  use,  used,  useful,  usefulness,  useless,  useless- 
ness,  uses,  using,  woman,  work. 

Inasmuch  as  the  frequency  tables  do  not  exhaust  all 
normal  possibilities  of  word  reaction,  a  certain  number  of 
reactions  which  are  essentially  normal  are  to  be  found  among 
individual  reactions.  In  order  to  separate  these  from  the 
pathological  reactions  an  appendix  to  the  frequency  tables 
has  been  compiled,  consisting  mainly  of  specific  definitions 
of  groups  of  words  which,  occurring  as  individual  reactions, 
are  to  be  counted  as  normal.     (See  p.  603.) 

Derivatives  of  Stimulus  Words. — Under  this  heading  is 
classed  any  reaction  which  is  a  grammatical  variant  or 
derivative  of  the  stimulus  word:  eating— eatables,  short — 
shortness,  sweet — sweetened. 

Sound  Reactions. — In  the  standardized  procedure  a  reac- 
tion is  placed  under  this  heading  when  50  per  cent  of  the 
sounds  of  the  shorter  word  of  the  pair  are  identical  with 
sounds  of  the  longer  word  and  are  ranged  in  the  same 
order. 

Among  sound  reactions  are  occasionally  found  neolo- 
gisms; for  these  a  separate  heading  is  provided. 

Word  Complements. — Here  is  included  any  reaction  which, 
added  to  the  stimulus  word,  forms  a  word,  a  proper  name, 
or  a  compound  word. 

Particles  of  Speech. — Under  this  heading  are  included 
articles,  numerals,  pronouns,  auxiliary  verbs,  adverbs  of 
time,  place  and  degree,  conjunctions,  prepositions,  and 
interjections. 


550  FREE  ASSOCIATION  TEST 

The  phenomenon  of  perseveration  occurs  in  cases  in  which 
there  is  abnormal  lack  of  mobility  of  attention.  The  names 
of  the  different  types  of  reactions  attributable  to  persevera- 
tion are  given  below  in  the  classification  table  and  are 
sufficiently  descriptive;  we  shall  refer  here  only  to  those 
which  require  further  definition. 

Association  to  Preceding  Stimulus. — Here  is  placed  any 
individual  reaction  that  is  shown  by  the  frequency  tables  to 
be  related  to  the  stimulus  preceding  the  one  in  question. 

Association  to  Preceding  Reaction. — If  either  the  reaction 
in  question  or  the  preceding  reaction  happens  to  be  one  of 
the  stimulus  words  on  the  list,  and  a  relationship  between 
the  two  be  found  to  exist  by  reference  to  the  frequency 
tables,  the  reaction  in  question  is  classified  under  this 
heading. 

In  cases  in  which  neither  the  reaction  in  question  nor  the 
preceding  reaction  happens  to  be  one  of  the  stimulus  words, 
but  a  relationship  between  them  may  be  judged  to  exist 
without  considerable  doubt,  the  reaction  in  question  is  also 
classed  here.  Example:  priest — father,  ocean — mother.  The 
latter  is  an  individual  reaction;  neither  the  word  father  nor 
mother  is  among  the  stimulus  words;  but  the  association 
between  the  words  father  and  mother  may  be  judged  to 
exist  without  considerable  doubt;  therefore  in  this  case 
mother  is  classed  as  an  association  to  preceding  reaction. 

Repetition  of  Previous  Stimulus. — Here  is  placed  any  reac- 
tion which  is  a  repetition  of  any  previous  stimulus  from 
amongst  the  ten  next  preceding,  at  the  same  time  placing 
repetition  of  preceding  stimulus  under  a  separate  heading. 

Neologisms. — Here  are  placed  the  newly  coined  words, 
so  commonly  given  by  psychotic  subjects,  excepting  such  as 
possess  a  sound  relationship  to  the  stimulus  word,  for  which, 
as  already  stated,  a  special  place  in  the  classification  has  been 
provided. 

Unclassified. — Into  this  group  fall  over  one  third  of  all 
individual  reactions,  it  having  been  found  impossible  to 
find  objective  criteria  for  their  more  definite  differentiation. 


CLASSIFICATION  OF  REACTIONS  551 

Order  of  Preference. — It  happens  not  infrequently  that  a 
reaction  presents  features  which  render  it  assignable  under 
two  or  more  headings  in  the  classification.  In  the  standard 
procedure  the  following  order  of  preference  is  used  for  guid- 
ance in  such  cases: 

Common  Reactions: 

1.  Specific. 

2.  Non-specific. 

3.  Doubtful  Reactions. 

Individual  Reactions: 

4.  Sound  reactions  (neologisms). 

5.  Neologisms  without  sound  relation. 

6.  Repetition  of  preceding  reaction. 

7.  Reaction  repeated  five  times. 

8.  Repetition  of  preceding  stimulus. 

9.  Derivatives. 

10.  Non-specific  reactions. 

11.  Sound  reactions  (words). 

12.  Word  complements. 

13.  Particles  of  speech. 

14.  Association  to  preceding  stimulus. 

15.  Association  to  preceding  reaction  (by  frequency  tables). 

16.  Repetition  of  previous  reaction. 

17.  Repetition  of  previous  stimulus. 

18.  Normal  (by  appendix). 

19.  Association  to  preceding  reaction  (without  frequency 
tables) . 

20.  Unclassified. 

In  Tables  18,  19,  and  20  are  given  results  obtained  and 
standards  estabhshed  by  means  of  the  Kent-Rosanoff  test 
applied  to  normal,  insane,  and  feeble-minded  subjects,  and  to 
white  and  negro  children  of  various  ages.  The  findings  in 
any  case  may  be  evaluated  by  comparison  with  these  tables. 


552 


FREE  ASSOCIATION  TEST 
TABLE  18 


Subjects. 


Common 
Reactions. 


Specific. 

% 


Non- 
specific. 

% 


Doubt- 
ful 
Reac- 
tions. 

% 


Individ- 
ual 

Reac- 
tions. 

% 


Failure 
of 
Reac- 
tion. 

% 


1000  normal  adults 

247  insane  adults 

253  defective  children  aged 

over  9  yrs 

125  normal  white  children 

11-15  yrs 

175  normal  white  children 

4-10  yrs 

125  normal  negro  children 

11-15  yrs 

175  normal  negro  children 

4-10  jTS 


85.5 
66.4 

75.2 

82.0 

62.7 

75.3 

54.1 


6.2 
4.3 

8.2 

7.2 

4.2 

7.2 

3.5 


1.5 
2.5 

2.1 

1.6 

3.2 

2.5 

2.5 


6.8 
26.8 

13.0 

8.6 

18.8 

14.9 

33.2 


1.5 
0.6 
11.1 
0.1 
6.7 


TABLE  19 


Types  of  Reaction.  ^ 


86  Normal 
Adults. 

% 


300  White 
Children. 

% 


300  Negro 
Children. 

% 


Normal  (by  appendix) 

Derivatives  of  stimulus  words 

Partial  dissociation  ^ 

Perseveration  ^ 

Neologisms  (without  sound  relation) 
Unclassified 


41.8 
0.3 
8.0 
6.1 

43.8 


20.0 
0.1 

11.1 

27.8 
0.6 

40.4 


12.3 
5.7 

16.7 

23.0 
0.3 

42.0 


^  The  Kent-Rosanoff  classification  was  used. 

2  Under  this  heading  are  included  the  following  varieties  of  reactions: 
non-specific,  sound  (words  and  neologisms),  word  complements,  and 
particles  of  .speech. 

'  Under  this  heading  are  included  the  following  varieties  of  reactions : 
association  to  preceding  stimulus,  association  to  preceding  reaction, 
repetition  of  preceding  stimulus,  repetition  of  previous  stimulus, 
repetition  of  preceding  reaction,  repetition  of  previous  reaction,  and 
reaction  repeated  five  times. 


CLASSIFICATION  OF  REACTIONS 
TABLE  20 


553 


Common 

Reactions. 

Doubtful 
Reactions. 

Individual 
Reactions. 

Failures  of 
Reaction. 

Group 
Ages 

in 
Years. 

Spe( 

^ific. 

Non- 
specific. 

White 

% 

Negro 

% 

White 

% 

Negro 

% 

White 

% 

Negro 

% 

White 

% 

Negro 

% 

White 

% 

Negro 

% 

4 

40.4 

37.5 

1.1 

1.0 

3.8 

2.3 

25.3 

40.9 

29.4 

18.4 

5 

55.1 

41.5 

2.0 

1.4 

4.4 

1.8 

21.4 

37.4 

17.1 

17.9 

6 

62.2 

52.1 

2.7 

2.2 

3.2 

2.6 

18.6 

37.6 

13.3 

5.5 

7 

64.9 

56.0 

4.0 

3.7 

3.5 

2.1 

20.0 

35.1 

7.6 

3.3 

8 

68.4 

59.3 

5.8 

5.4 

3.1 

3.2 

18.0 

31.0 

4.7 

1.2 

9 

75.1 

62.3 

5.5 

6.5 

1.7 

2.6 

14.2 

27.7 

3.5 

0.9 

10 

72.9 

70.0 

8.4 

4.4 

2.3 

2.7 

14.3 

23.4 

2.1 

0.1 

11 

82.0 

74.8 

7.1 

7.0 

1.7 

2.6 

8.6 

15.5 

0.6 

0.1 

12 

83.8 

74.2 

6.6 

7.5 

1.3 

2.4 

7.6 

15.6 

0.7 

0.2 

13 

81.1 

74.2 

8.4 

7.2 

1.8 

2.6 

8.5 

15.8 

0.2 

0.2 

14 

84.1 

77.2 

6.3 

7.8 

1.4 

2.6 

7.7 

12.4 

0.5 

0.1 

15 

78.7 

76.3 

7.6 

6.2 

2.0 

2.2 

10.8 

15.2 

0.9 

0.1 

554 


FREE  ASSOCIATION  TEST 


THE  FREQUENCY  TABLES. 


1.  TABIiD 

1  accommodation 

2  dine 

1  kitchen 

1  operating 

1  stable    ■ 

8  article 

4  dining 

2  ornament 

86  stand 

1  articles 

26  dinner 

1  lamp 

3  stool 

5  dish 

4  large 

1  parlor 

1  straight 

1  basket 

40  dishes 

1  leaf 

1  pitcher 

1  strong 

9  bench 

1  dissection 

1  leaves 

4  plate 

1  supper 

14  board 

1  dog 

1  library 

1  plates 

7  book 

13  leg 

]  plateau 

1  tablecloth 

5  books 

63  eat 

10  legs 

1  polished 

1  tea 

1  boy 

1  eatables 

2  linen 

1  timber 

1  bread 

34  eating 

1  long 

1  refreshments 

2  top 

2  breakfast 

2  low 

3  rest 

I  typewriter 

2  broad 

1  ferns 

3  room 

1  brown 

1  fete 

1  Mabel 

10  round 

2  use 

1  butter 

5  flat 

2  mahogany 

3  useful 

7  floor 

1  mat 

1  school 

1  utensil 

2  cards 

2i)  food 

6  meal 

1  serviceable 

1  celery 

1  fork 

4  meals 

2  set 

2  TictualB 

1  center 

1  form 

2  meat 

1  shiny 

367  chair 

75  furniture 

1  mess 

3  sit 

1  wagon 

7  chairs 

2  sitting 

1  whist 

I  chemical 

1  glass 

2  nails 

1  slab 

1  whitie 

67  cloth 

1  napkin 

1  smooth 

1  wire 

1  cockroaches 

9  hard 

1  number 

1  soup 

76  wood 

1  comfort 

1  hat 

1  spiritualism 

1  wooden 

J 7  cover 

2  home 

1  oak 

0  spoon 

2  work 

1  cutlery 

3  house 

1  object 

2  spread 

1  working 

1  old 

9  square 

2  write 

11  desk 

1  ink 

2.  DARK 

e  writing 

6  afraid 

2  cold 

2  fair 

427  light 

1  scare 

28  color 

6  fear 

1  lonely 

1  shades 

1  baby 

1  colored 

1  fearful 

1  lonesome 

2  shadow 

1  bad 

1  colorless 

1  fearsome 

1  lonesomeness 

1  shadows 

1  barks 

1  coon 

2  fright 

1  sky 

76  black 

1  curly 

1  mahogany 

1  sleep 

2  blackness 

1  ghost 

4  man 

1  sleeping 

1  blank 

1  day 

1  ghosts 

1  mice 

1  space 

2  blind 

1  daylight 

6  gloom 

1  midnight 

1  starry 

2  blindness 

1  dead 

11  gloomy 

6  moon 

2  stars 

5  blue 

1  denseneas 

1  gray 

1  moonlight 

1  stillness 

1  board 

3  dim 

1  green 

1  mysterious 

1  storm 

1  boat 

3  dimness 

1  ground 

1  stumbling 

15  brisht 

2  dinsy 

1  rice 

1  subject 

4  brightness 

3  dismal 

5  hair 

221  night 

1  sunlight 

4  brown 

1  dog 

1  hall 

1  door 

1  hell 

1  oblivion 

1  thunder 

1  candle 

1  dreary 

1  hole 

1  obscure 

1  tree 

1  cart 

4  dress 

3  horse 

1  twilight 

2  cat 

5  dungeon 

2  house 

1  parlor 

1  cell 

1  dusk 

1  prison 

1  unseen 

6  cellar 

1  dusky 

1  illumination 

1  close 

2  invisible 

6  red 

1  walk 

1  closet 

4  evening 

3  rest 

8  weather 

2  cloud 

1  eye 

1  lamp 

22  room 

»  white 

2  clouds 

2  eyes 

1  lantern 

1  woods 

8  cloudy 

FREQUENCY  TABLES 


555 


3.  MUSIC 

t  Accordion 

17  daiicff 

1  harmonious 

1  noisy 

12  sing 

3  air 

1  dances 

15  harmony 

2  note 

1  singer 

1  amuse 

15  dancmg 

1  hear 

17  notes 

48  singing 

JO  amusement 

1  delieht 

2  heaven 

1  soft 

7  art 

2  delightful 

1  hurdygurdy 

6  opera 

1  softness 

1  attention 

3'  discord 

1  hymn 

6  orchestra 

1  solemn 

1  attractioa 

1  drama 

1  idealism 

6  organ 

68  song 
6  songs 

6  band 

3  ear 

21  instrument 

2  paper 

2  soothing 

1  bassviol 

1  ecstasy 

5  instruments 

1  pastime 

95  sound 

7  beautiful 

1  elevating 

1  instrumental 

ISO  piano 

2  sounds 

2  beauty 

1  enchantment 

2  pianola 

2  stool 

7  Beethoven 

1  enjoyable 

1  jolly 

1  pitch 

1  strain 

1  bell 

1  enjoyed 

11  joy 

7  play 

2  strains 

1  bird 

13  enjoyment 

1  joyful 

8  playing 

1  string 

1  bird3 

6  entertaining 

10  pleasant 

2  study 

1  book 

3  entertainment 

1  lesson 

1  pleasantness 

47  sweet 

2  books 

1  entrancing 

1  light 

6  pleasing 

6  sweetness 

2  box 

1  line 

31  pleasure 

4  sjmphony 

1  brightness 

1  feeling 

I  liveliness 

1  poem 

1  fiddle 

1  lonely 

'4  poetry 

2  talent 

1  captivating 

2  fine 

1  loud 

1  practice 

6  teacher 

1  cats 

1  flowers 

2  love 

.4  pretty 

1  teaching 

1  charm 

1  flute 

1  pupils 

1  thought 

1  charms 

1  fun 

1  man 

2  time 

2  charming 

1  meditation 

1  quiet 

3  tone 

2  cheerful 

2  gaiety 

24  melody 

1  town 

2  cheerfulness 

1  gay 

1  Mendelssohn 

1  rack 

2  tune 

1  Chopin 

1  genius 

1  Merry   Widow 

1  racket 

1  chord 

2  girl 

1  Mozart 

1  rhvme 

21  violin 

1  chords 

1  gladness 

1  Mr.   B. 

2  roll 

2  voice 

1  clarinette 

1  Goethe 

1  Mrs.    E. 

1  room 

1  classic 

3  good 

8  musician 

S  Wagner 

2  classical 

1  guitar 

1  mute 

2  sadness 

1  wa\'y 

2  composer 

1  scale 

1  windo\Y 

1  company 

2  hall 

6  nice 

2  Schubert 

1  words 

2  concert 

6  happiness 

1  nocturne 

1  score 

i  worship 

1  conductor 

2  happy 

16  noise 
4.  SICKNESS 

6  sheet 
1  sheets 

1  Yankee    Doodli 

1  afiiictiDn 

2  disabled 

2  home 

1  operation 

2  sorry 

J  aire 

3  discomfort 

1  horrible 

1  oranges 

1  stomach 

S  ailing 

29  disease 

9  hospital 

2  strength 

2  ailment 

4  distress 

36  pain 

1  suffer 

1  air 

62  doctor 

48  ill 

1  painful 

12  sufering 

1  anxiety 

1  dread 

71  iUness 

2  pale 

1  summer 

3  appendicitis 

1  dreariness 

1  incompetence 

7  patient 

2  sympathy 

1  aunt 

1  inconvenience 

1  patients 

1  enjoyed 

1  indisposition 

1  people 

1  terror 

1  baby 

1  ether 

1  infirmary 

1  person 

1  totrether 

15  bad 

1  exhaustion 

1  insanity 

7  phvsician 

20  trouble 

64  bed 

2  invalid 

1  pill 

1  trving 

1  Bertha 

1  family 

1  nills 

6  typhoid 

1  better 

3  father 

1    K. 

1  pi  a  true 

1  body 

1  fear 

1  pleasantness 

2  uncomfortable 

1  business 

4  feeble 

1  low 

5  Dneumonia 

1  unV-appiness 

1  fepl 

1  lying 

1  poverty 

1  unhappv 

1  calamity 

1  feeling 

4  unhenlfhy 

1  care 

9  fever 

2  malady 

1  ouiet 

5  unpleasant 

2  child 

1  fevers 

1  rnan 

1  quietness 

2  unpleasantns« 

1  cold 

1  fracture 

8  measles 

11  unwell 

1  condition 

1  fright 

1  medication 

3  recovery 

3  consumption 

29  medicine 

1  relapsing 

1  want 

2  contaarious 

1  gloom 

1  melancholy 

1  rheumatism 

1  weak 

1  convalescence 

1  eravel 

1  mine 

1  room 

11  wenkness 

2  convalescing 

2  grief 

3  misery 

2  wealth 

3  cure 

1  grunting' 

3  misfortune 

7  sad 

1  weariness 

3  mother 

9  sadness 

1  weary 

1  danger 

2  hard 

3  serious 

40  well 

115  d=ath 

1  hatefulness 

2  nervousness 

4  severe 

1  white 

1  dietary 

6  headache 

1  neuralgia 

1  sigh 

1  worried 

8  dinhtneria 

142  health 

15  nurse 

1  sore 

1  worrlroent 

1  disability 

4  healthy 

2  nursing 

24  sorrow 

556 


FREE  ASSOCIATION  TEST 


5.  MAR 

2  adult 

1  companion 

1  homely 

6  masculine 

1  self 

1  affection 

1  company 

1  horrible 

1  mason 

4  sex 

1  ape 

1  coon 

4  horse 

1  mind 

1  shirt 

1  alive 

1  crank 

1  house 

1  misht 

1  shoes 

12  animal 

8  creature 

22  human 

1  minister 

1  short 

1  animals 

1  cross 

1  humanity 

1  minor 

1  smoking 

1  animate 

4  husband 

1  misery 

1  stern 

2  annearance 

1  devil 

1  money 

1  stout 

2  doctor 

1  individual 

1  monkey 

1  street 

1  baby 

1  dress 

1  insane 

1  Mr.  D. 

82  strength 

2  bad 

1  institution 

1  Mr.   H. 

8  strong 

1  heard 

1  educator 

1  intellectual 

1  Mr.    N. 

1  sweetheart 

2  bpast 

1  existence 

1  intelligent 

3  Mr.  S. 

19  heinff 

1  muscular 

1  Taft 

8  biDed 

1  fakir 

1  janitor 

12  tall 

1  blond 

1  false 

1  Joe 

1  N. 

1  thought 

8  body 

1  family 

1  natTire 

6  trousers 

44  boy 

15  father 

1  labor 

1  Ned 

1  true 

1  brain 

3  female 

2  laborer 

1  nice 

1  britrht 

2  flesh 

7  lady 

8  noble 

1  unfeminine 

1  briehtness 

2  form 

11  large 

1  nuisance 

1  use 

8  brother 

1  fraud 

4  life 

1  brntherhood 

1  Fred 

1  Heht 

1  out 

IV. 

1  brute 

2  friend 

1  limb 

1  voter 

1  bum 

2  living 

1  papa 

6  business 

1  pentle 

1  lord 

1  passion 

1  walk 

7  gentleman 

1  love 

2  people 

1  wedding 

8  cane 

6  pirl 

80  person 

1  whiskers 

1  certain 

1  elacier 

1  machine 

1  pleasure 

5  wife 

2  ChRrles 

10  pood 

1  maiden 

2  policeman 

1  wise 

in  child 

1  greatness 

99  male 

1  politician 

894  woman 

2  childrrn 

1  grown 

1  mammal 

5  power 

17  work 

1  Christian 

1  growth 

1  manhood 

1  professor 

1  works 

1  olertrvmaD 

5  mankind 

1  prosperity 

1  worker 

7  clothes 

1  hair 

1  manlinea 

1  provider 

8  working 

2  clothing 

7  hat 

2  manly 

8  coat 

2  help 

1  marriage 

1  Roosevelt 

2  young 

1  comfort 

1  home 

1  married 
6.  DEEP 

1  ruler 

8  aft^-sa 

4  darkness 

1  heavy 

1  precipice 

1  story 

1  altitude 

1  dense 

5  height 

4  profound 

1  strong 

1  around 

31  depth 

37  hiph 

J  study 

1  depths 

32  hole 

1  ravine 

1  sunken 

8  hclnw 

1  diameter 

13  hollow 

1  reaching 

1  surface 

1  beneath 

1  die: 

13  river 

1  swimming 

1  hlnck 

8  distance 

3  large 

1  rocks 

8  bine 

3  ditch 

8  length 

1  thick 

1  bottom 

1  dolrful 

2  level 

1  safety 

1  thickness 

1  bottomless 

27  down 

4  lisht 

1  scare 

1  thin 

1  bowl 

1  dread 

18  long 

90  sea 

2  thinking 

1  breath 

51  low 

1  spwer 

14  thought 

2  broad 

1  earth 

1  shade 

2  thoughts 

1  brooding 

1  extension 

2  measure 

1  shady 

1  tranquil 

1  brook 

1  miirhty 

180  shallov^ 

1  trench 

2  fall 

1  mind 

1  sharp 

2  cave 

3  falling 

4  mine 

1  ship 

1  under 

1  Ca.viiga 

3  far 

1  short 

1  chair 

5  fathomless 

3  narrow 

1  sincere 

1  valley 

2  chiism 

1  fear 

2  sink 

2  vast 

1  cellar 

1  full 

S3  ocean 

1  sleep 

1  clnssic 

1  organ 

1  smooth 

1  wading 

1  clear 

1  gloomy 

1  sorrow 

134  water 

1  cliff 

1  good 

1  philosophy 

2  sound 

44  well 

1  gorge 

1  pit 

6  space 

1  wet 

8  dancer 

1  great 

1  r'ond 

2  spacious 

12  wide 

6  dangerous 

1  ground 

1  pool 

7  Bleep 

2  width 

28  dark 

FREQUENCY  TABLES 


557 


<T.  SOFT 

I  apple 

1  dark 

3  gentle 

1  membrane 

3  snap 

1  dough 

1  girl 

2  mild 

7  snow 

7babv 

6  down 

1  glove 

1  moist 

6  soap 

2  ball 

8  downy 

3  good 

2  moss 

1  soup 

1  beautiful 

1  dress 

1  grasp 

15  mud 

22  sponge 

12  bed 

1  drink 

1  grass 

10  mush 

1  sponges 

1  boiled 

3  ground 

1  mushing 

8  spongy 

1  brain 

7  earth 

1  gum 

12  mushy 

1  squash 

4  bread 

1  ease 

4  music 

1  sticky 

1  breeze 

34  easy 

8  hair 

1  strong 

12  butter 

4  egg 

S  hand 

4  nice 

I  substance 

2  eggs 

1  hands 

8  sweet 

1  cake 

1  elastic 

365  hard 

1  palatable 

1  sweetness 

1  candy 

1  eyes 

1  harsh 

2  peach 

1  care 

1  hazy 

2  pear 

8  tender 

1  carpet 

2  feather 

1  head 

53  pillow 

1  texture 

1  cat 

24  feathers 

2  pillows 

1  timid 

1  cement 

1  feathery 

1  idiot 

8  pliable 

1  tomatoes 

1  clay 

1  feel 

2  plush 

4  touch 

1  clean 

8  feeling 

1  jelly 

4  pudding 

S  cloth 

1  felt 

4  putty 

1  uncooked 

1  clothes 

6  fine 

2  kitten 

2  coal 

1  firm 

1  quality 

15  velvet 

1  cold 

3  flabby 

1  large 

8  quiet 

2  voice 

'2  color 

1  fleece 

8  light 

2  comfort 

1  flesh 

1  lightly 

3  rubber 

I  wadding 

5  comfortable 

7  flexible 

2  liquid 

1  warm 

1  comply 

1  floor 

2  loose 

1  sand 

8  water 

1  consistency 

1  fluffy 

5  loud 

1  satisfactory 

1  watery 

28  cotton 

2  food 

5  low 

1  seat 

1  wax 

1  crabg 

1  foolish 

10  silk 

3  wet 

2  cream 

1  form 

1  maple 

1  skin 

8  white 

1  creeping 

3  fruit 

1  marshes 

2  slow 

8  wool 

25  cushion 

1  fun 

1  medium 

1  slushy 

1  woolen 

JLtai 

11  mellow 
&  ElATIKG 

27  smooth 

6  yielding 

1  abstain 

1  enjoyable 

2  ice-cream 

1  olives 

2  Blow 

1  abstinence 

1  enjoying 

4  indigestion 

1  oranges 

1  slowly 

2  action 

2  enjoyment 

2  soup 

28  appetite 

1  enough 

1  knives 

2  palatable 

4  starving 

4  apple 

1  etiquette 

3  people 

2  steak 

6  apples 

1  lemons 

3  pie 

2  stomach 

1  assimilation 

3  fast 

2  life 

7  pleasant 

J  strawberries 

5  fasting 

4  live 

1  pleasantness 

2  strength 

1  biting 

1  fattening 

6  living 

10  pleasure 

1  3>ibstanqe 

46  bread 

2  feasting 

1  lobster 

1  plenty 

Z  sufficient 

7  breakfast 

1  feed 

1  lobsters 

1  poor 

I  sugar 

1  butter 

5  feeding 

8  lunch 

1  potato 

1  surfeiting 

2  filling 

2  potatoes 

;1  sustaining 

4  cake 

1  finishing 

1  masticate 

1  provisions 

2  sustenance 

8  candy 

3  fish 

11  masticating 

1  pudding 

6  swallow 

1  Chacona'8 

1  flavor 

5  mastication 

6  swallowing 

1  chew 

1  flesh 

1  matter 

1  quick 

27  chewing 

170  food 

4  meal 

1  quickly 

21  table 

3  chicken 

2  fork 

10  meals 

1  talking 

1  coffee 

1  forks 

11  meat 

2  refreshing 

3  taste 

1  Commons 

8  fruit 

1  meeting 

1  refreshment 

2  tasting 

4  consuming 

4  full 

1  mild 

1  Reisenweber 

3  teeth 

8  cooking 

1  milk 

1  relief 

1  thinking 

2  cream 

1  gluttonlsh 

1  more 

2  relish 

1  throat 

23  good 

1  motion 

2  resting 

1  tongue 

1  devour 

1  gormandizer 

2  mouth 

1  room 

2  devouring 

1  gratifying 

1  movement 

1  use 

2  diet 

1  much 

1  sandwich 

1  utensils 

1  diets 

8  habit 

1  myself 

12  satipfactior 

1  digest 

9  health 

4  satisfied 

8  vegetable 

7  digesting 

1  healthful 

4  necessary 

1  satisfy 

8  vegetables 

10  digestion 

1  heartily 

7  necessity 

6  satisfying 

4  victuals 

2  dine 

1  hearty 

3  nice 

1  sick 

1  dining 

2  hot 

1  nourish 

1  sit 

2  want 

81  dinner 

1  house 

2  nourishing 

1  sitting 

1  water 

6  drink 

19  hunger 

11  nourishment 

1  sleep 

1  watermelon 

166  drinking 

44  hungry 

17  sleeping 

2  well 

1  dyspepsia 

1  work 

558 


FREE  ASSOCIATION  TEST 


9.   MOUNTAIN 


1  abrasion 

1  dirt 

2  hilly 

1  Mount  Pleasant    1  shadows 

4  Adirondacks 

1  distance 

1  Himalaya 

1  Mount    Shasta 

1  shooting 

2  air 

1  ditch 

6  hollow 

1  Mount  Wilson 

1  size 

3  Alleghany 

1  Holyoke 

2  sky 

6  Alps 

3  earth 

1  home 

2  object 

1  slope 

2  altitude 

9  elevation 

1  horse 

1  Owl's  Head 

10  snow 

1  attractive 

1  Hudson 

12  steep 

1  automobile 

1  fear 

2  huge 

16  peak 

1  steepness 

1  field 

1  peaks 

2  stone 

1  Bald 

1  Flashman 

1  impressive 

1  pictures 

1  stones 

1  beautiful 

1  foliage 

1  incline 

1  Pike's  Peak 

2  stream 

2  beauty 

1  fountain 

1  island 

1  pines 

4  summit 

2  big 

11  plain 

2  Switzerland 

1  Blanc 

1  Galeton 

1  Kipling 

1  plateaus 

1  Bluff 

1  geography 

1  knoll 

3  pleasure 

1  tall 

1  Breckenridge 

1  grand 

1  pointed 

1  Terrace 

3  grandeur 

8  lake 

5  top 

1  camping 

1  granite 

6  land 

1  railway 

2  tree 

8  Catskills 

1  grass 

1  landscape 

3  range 

17  trees 

2  cliff 

1  great 

4  large 

1  ranges 

1  cliffB 

4  green 

1  level 

8  river 

1  up 

1  Clifton 

1  ground 

1  lofty 

10  rock 

9  climb 

2  low 

6  Rockies 

2  vale 

27  climbing 

1  heath 

1  lowland 

18  rocks 

90  valley 

1  close 

73  height 

5  rocky 

5  valleys 

3  clouds 

2  heights 

1  Monodonack 

1  rough 

1  Vermont 

1  cone 

246  high 

t  mound 

2  view 

5  country 

1  highlands 

1  Mount  Ivy 

1  scene 

2  volcano 

1  crevice 

2  highness 

1  Mount  Kear- 

3  scenery 

184  hill 

sarge 

1  sea 

1  AVashington 

1  descend 

32  hills 

1  Mount   McKin- 

1  seas 

5  White 

2  descending 

2  hilltop 

ley 

1  seashore 

1  wood 

1  desert 

1  hilltops 

10.  HOUSE} 

3  woods 

15  abode 

1  corridor 

1  habitable 

2  mouse 

1  star 

1  alley 

42  cottage 

5  habitation 

1  steps 

3  apartmenc 

3  cover 

1  happiness 

1  new 

7  stone 

1  covering 

2  height 

1  stoop 

1  background 

3  high 

1  object 

2  store 

74  bam 

1  dark 

3  hill 

1  old 

7  street 

1  Bay    Ridge 

1  den 

103  home 

1  ours 

8  structure 

2  beautiful 

2  dog 

1  homeless 

1  Belknap 

1  domestic 

4  hospital 

1  palace 

1  tabernacle 

4  big 

1  domicile 

1  hot 

1  painting 

1  table 

1  blinds 

16  door 

5  hotel 

1  Pasadena 

1  tall 

3  boards 

1  doors 

1  hovel 

11  people 

1  telescope 

2  boat 

3  dwell 

2  hut 

2  piazza 

1  tenant 

Ibox 

68  dwelling 

1  picture 

2  tenement 

23  brick 

1  inhabitant 

6  place 

3  tent 

5  bricks 

1  enclosure 

1  inhabited 

1  pleasant 

1  timber 

2  brown 

1  erection 

1  inmates 

3  pretty 

5  top 

2  build 

1  into 

1  property 

1  town 

78  building 

4  family 

3  protection 

2  tree 

2  bungalow 

1  fancy 

.    1  joy 

1  trees 

2  farm 

4  red 

1  tumbler 

8  cabin 

1  farmer 

10  land 

1  refuge 

1  camp 

1  fence 

1  lake 

19  residence 

2  villa 

1  carpenter 

1  field 

24  large 

2  resident 

1  village 

1  carpet 

1  fire 

3  lawn 

1  restful 

4  castle 

1  floor 

1  lemon 

1  road 

1  walls 

1  cattle 

1  form 

1  Leonia 

12  roof 

3  warm 

1  cellar 

1  foundation 

2  life 

9  room 

1  wealth 

2  chair 

6  frame 

33  live 

8  rooms 

1  well 

1  chamber 

1  friends 

19  living 

9  white 

1  chicken 

1  furnace 

18  lot 

1  Sage 

1  Whittier 

5  chimney 

1  furnishing 

1  lots 

2  school 

1  wide 

1  church 

11  furniture 

3  lumber 

1  sea 

1  willow 

2  city 

1  shanty 

9  window 

2  clean 

10  garden 

2  man 

5  shed 

6  windows 

1  closed 

1  grandmother 

14  mansion 

22  shelter 

31  wood 

1  college 

1  great 

1  material 

2  sky 

1  wooden 

9  comfort 

2  green 

1  mine 

2  small 

1  workman 

1  comforts 

3  ground 

1  mortgage 

1  spacious 

1  worehip 

3  comfortable 

1  grounds 

1  Mountain 

4  square 

1  contractor 

House 

3  stable 

10  yard 

FREQUENCY  TABLES 


559 


11.   BLACK 

1  agreeable 

36  darkness 

2  hair 

1  obscure 

2  somber 

4  death 

3  hat 

1  orange 

1  soot 

8  blue 

1  dense 

1  heavy 

4  sorrow 

3  board 

1  desolate 

1  hog 

4  paint 

1  space 

2  book 

2  dirty 

1  horror 

1  paper 

1  spectrum 

2  bright 

1  disagreeable 

6  hof  se 

1  pen 

1  stocking 

1  buggy 

1  dislike 

2  pink 

1  stockings 

4  dog 

1  impenetrable 

1  pipe 

1  suit 

8  cat 

1  domino 

14  ink 

1  pit 

1  chair 

29  dress 

1  table 

1  charcoal 

2  dye 

1  lack 

1  radiator 

1  tar 

17  cloth 

12  light 

4  red 

1  terror 

4  clothes 

1  earth 

1  ribbon 

1  tie 

1  cloud 

1  ebony 

1  mammy 

1  robe 

1  clouda 

2  man 

1  imibrella 

2  cloudy 

1  face 

1  Mrs.   B. 

1  sad 

3  coal 

2  fear 

2  mournful 

2  sadness 

1  velvet 

3  coat 

1  figure 

17  mourning 

1  sack 

129  color 

1  flecked 

1  mud 

1  shady 

2  wall 

1  colored 

1  floor 

2  sheep 

1  water 

3  colorless 

1  funeral 

7  negro 

4  shoe 

339  white 

1  coon 

1  negroes 

1  shoes 

1  wonder 

2  crepe 

2  gloomy 

6  nigger 

1  sign 

1  wood 

1  curtain 

1  gown 

61  night 

2  skirt 

2  gray 

1  nothing 

1  Ek> 

2  yellow 

172  dart 

7  green 

la.  MUTTON 

9  animal 

1  delicious 

1  goat 

1  Mary 

laoft 

1  animals 

6  dinner 

9  good 

257  meat 

2  soup 

1  appetite 

2  disagreeable 

1  grass 

1  mouse 

1  stale 

1  Australia 

1  dish 

2  grease 

1  muttonhead 

3  steak 

2  dislike 

1  greasy 

2  stew 

1  baa 

1  disliked 

2  nice 

2  strong 

67  beef 

2  ham 

1  bony 

14  eat 

1  hate 

1  old 

4  table 

1  breakfast 

7  eatable 

2  head 

6  tallow 

15  broth 

10  eating 

1  horrid 

1  pastures 

3  tender 

1  brown 

1  peas 

1  thinking 

2  butcher 

7  fat 
2  field 

1  indigestion 

2  pig 

3  pork 

6  tough 

2  calf 

10  flesh 

1  knife 

1  uncle 

1  cattle 

1  flock 

1  rare 

3  cheap 

30  food 

121  lamb 

4  roast 

30  veal 

34  Chop 

1  fork 

2  lambs 

1  vegetables 

83  chops 

1  fowl 

6  leg 

1  sauce 

1  vegetarian. 

2  cow 

204  sheep 
1  smeU 

4  wool 

560 


FREE  ASSOCIATION  TEST 


13.     COMFORT 


1  agony 

1  driving 

1  justice 

1  please 

11  solid 

1  annoyance 

77  pleasure 

3  solitude 

165  ease 

1  kindness 

1  plentiness 

2  soothing 

1  bad 

11  easiness 

1  plenty 

5  sorrow 

42  bed 

61  easy 

1  lamp 

1  Polly 

1  speak 

4  blanket 

1  eating 

2  laziness 

1  post 

1  spirit 

1  book 

1  enjoying 

1  lazy 

1  spread 

1  books 

6  enjoyment 

6  leisure 

6  quiet 

1  suffering 

1  less 

1  quietness 

1  sweet 

1  oanoe 

1  feather 

1  life 

7  quilt 

1  swing 

4  care 

1  feeling 

1  like 

81  chair 

2  fireplace 

2  living 

1  rain 

2  table 

1  cheer 

2  fireside 

1  loneliness 

1  relief 

1  taken 

1  children 

1  friends 

6  lounge 

53  rest 

1  tea 

1  cloth 

1  luxurious 

1  restful 

1  thankfulness 

4  comfortable 

1  God 

23  luxury 

1  restfulness 

1  tired 

1  comforter 

5  good 

5  resting 

1  trials 

2  consolation 

1  goodness 

1  man 

1  rich 

1  trouble 

1  console 

1  great 

1  mansion 

3  rocker 

1  consoling 

1  grief 

1  miserable 

1  uncomfort 

2  content 

9  misery 

1  safety 

10  uncomfortable 

4  contentment 

7  hammock 

9  money 

1  salary 

3  uneasiness 

2  convenience 

50  happiness 

3  mother 

4  satisfaction 

3  uneasy 

1  cozy 

17  happy 

3  satisfied 

1  unrest 

9  couch 

2  hard 

1  neatness 

1  security 

1  unwell 

1  cover 

7  hardship 

4  nice 

1  settled 

1  covering 

1  healing 

1  none 

1  sick 

6  warm 

4  cushion 

15  health 

2  nurse 

3  sickness 

4  warmth 

1  cushions 

3  help 

1  sit' 

6  wealth 

63  home 

4  pain 

4  sitting 

8  well 

1  davenport 

4  house 

2  palace 

10  sleep 

1  well-being 

1  death 

1  household 

1  patient 

1  slippers 

1  wine 

1  delighthil 

12  peace 

1  slumber 

1  wish 

2  desirable 

11 

1  people 

1  smoke 

1  woman 

24  discomfort 

1  idleness 

2  pillow 

1  smoking 

1  wool 

1  disease 

1  ill 

1  pipe 

5  sofa 

1  work 

1  displeasure 

1  playing 

2  soft 

4  distress 

9  joy 

9  pleasant 
14.  HAND 

1  solace 

lye 

2  anatomy 

11  feel 

2  instrument 

1  narrow 

1  shapely 

63  arm 

5  feeling 

2  necessity 

1  shop 

2  arms 

35  feet 

1  jewel 

1  nice 

1  shoulder 

2  fellowship 

1  nimble 

4  skin 

I  ball 

39  finger 

1  kindness 

1  nose 

1  slim 

8  beautiful 

83  fingers 

1  knife 

8  small 

S  black 

1  fist 

1  knitting 

1  object 

1  soap 

1  bleeding 

19  flesh 

4  organ 

8  soft 

48  body 

204  foot 

1  labor 

1  something 

1  bone 

1  form 

1  large 

5  palm 

1  sore 

1  bones 

1  formation 

4  leg 

1  part 

6  strength 

1  busy 

1  friend 

1  legs 

2  paw 

8  strong 

1  friendship 

1  lemon 

1  pencil 

1  support 

2  cards 

1  fruit 

2  life 

1  perfect 

1  system 

1  clean 

48  limb 

10  person 

1  clock 

1  give 

1  limbs 

1  piano 

1  fable 

1  convenience 

20  glove 

1  long 

1  pen 

1  thread 

1  cradle 

5  gloves 

1  love 

3  power 

9  touch 

1  cunning 

1  good 

3  pretty 

2  two 

8  grasp 

2  machine 

1  purity 

1  dexterity 

1  greeting 

1  maid 

12  use 

I  diligence 

8  grip 

3  man 

1  reach 

24  useful 

1  dissecting 

1  manipulation 

1  rest 

4  usefulness 

1  do 

1  handle 

14  memijer 

11  right 

2  doing 

3  handy 

1  mind 

23  ring 

1  watch 

1  dog 

1  hard 

1  mine 

2  rings 

1  woman 

1  head 

4  mouth 

49  work 

1  ear 

2  heart 

1  move 

1  satisfaction 

15  white 

1  elbow 

6  help 

4  muscle 

1  servant 

"  4  wrist 

6  extremity 

2  helper 

2  sew 

8  write 

1  helping 

2  nail 

2  sewing 

11  writing 

7  face 

3  hold 

1  nails 

9  shake 

1  fat 

1  holding 

2  human 

1  name 

1  shape. 

I  you 

FREQUENCY  TABLES 


561    • 


16.  SH0R1 

2  abbreviated 

1  down 

1  lake 

1  petticoat 

%  strong 

1  aee 

1  drawn 

2  large 

1  pin 

1  stubborn 

2  ami 

3  dress 

2  leg 

ipity 

B  stubby 

2  dumpy 

18  length 

1  plant 

4  stumpy 

1  baby 

11  dwarf 

1  lesson 

1  plants 

1  stunned 

1  beach 

1  dwarfs 

1  lessons 

1  pony 

1  stunted 

1  beam 

5  life 

2  post 

1  sufficient 

1  board 

2  easy 

15  little 

2  pygmy 

1  sum 

8  boy 

1  elongated 

1  line 

1  sweet 

1  brevity 

1  extension 

1  lived 

8  quick 

1  brick 

279  long 

1  quickly 

168  tall 

7  brief 

4  fat 

11  low 

6  thick 

i  broad 

1  finger 

1  lowly 

1  road 

1  thin 

1  build 

1  flowerpot 

1  round 

8  time 

2  foot 

20  man 

1  tiny 

1  C. 

2  friend 

3  measure 

1  session 

1  Tom  Thumb 

1  cake 

1  measurements 

1  shallow 

1  tree 

1  chair 

11  girl 

2  medium 

1  sister 

1  change 

1  good 

1  midget 

5  size 

1  unpleasant 

4  child 

1  grandmother 

1  millimeter 

1  skirt 

1  useless 

1  children 

5  grass 

1  minus 

1  sleek 

1  clock 

1  Miss  K. 

1  slight 

1  vacation 

1  cloth 

2  hair 

1  money 

1  slightly 

1  comfort 

1  happiness 

1  mother 

136  small 

1  walsted 

1  compact 

13  height 

6  myself 

1  space 

8  walk 

1  cut 

4  high 

2  speech 

1  want 

1  cylinder 

1  hour 

1  name 

1  square 

2  wanting 

3  hours 

1  narrow 

1  staccato 

1  water 

1  dainty 

1  near 

2  stature 

1  weU 

i  day 

5  inch 

1  needle 

2  stem 

1  wide 

2  deficient 

1  not 

8  stick 

6  woman 

1  dimension 

2  journey 

2  stop 

1  wood 

1  dirainiature 

1  out 

1  story 

1  worm 

2  diminutive 

1  Karl 

24  stout 

1  disagreeable 

6  pencil 

1  strawberries 

X  you 

10  distance 

1  lacking 

3  people 

2  street 

1  dot 

4  lady 

15  person 
16.  FRUIT 

1  string 

2  acid 

1  easy 

8  health 

25  orange 

2  appetite 

62  eat 

3  healthy 

20  oranges 

1  salad 

157  apple 

S3  eatable 

1  home 

6  orchard 

5  seed 

102  apples 

15  eatables 

J.  outcome 

1  sickness 

1  article 

35  eating 

1  Italians 

4  sour 

1  edible 

1  invigorating 

2  palatable 

1  south 

1  bake 

1  eggs 

1  jam 

17  peach 

1  spring 

11  banana 

2  enjoyment 

6  juice 

82  peaches 

1  stalk 

8  bananas 

5  juicy 

24  pear 

1  stand 

7  berries 

1  figs 

11  pears 

1  stems 

1  berry 

Iflsh 

1  knife 

1  picking 

1  store 

1  blackberries 

1  flesh 

1  pie 

2  strawberries 

2  bread 

3  flower 

2  lemon 

2  pineapple 

1  strawberry 

3  flowers 

1  liked 

1  plant 

2  summer 

2  cake 

1  fond 

1  love 

1  plants 

1  swallow 

1  can 

22  food 

3  luscious 

2  pleasant 

24  sweet 

1  candies 

1  fresh 

2  luxury 

1  pleasure 

1  sweets 

3  candy 

2  plenty 

2  cherries 

2  garden 

4  meat 

2  plum 

3  table 

2  cherry 

24  good 

1  medicine  • 

2  produce 

5  taste 

1  country 

2  grain 

1  melon 

I  prune 

85  tree 

1  currants 

4  grape 
14  grapes 

1  milk 

1  raspberries 

27  trees 

1  dainty 

1  grapefruit 

1  nourishing 

1  raspberry 

75  vegetable 

2  delicacy 

1  green 

2  nourishment 

1  red 

28  vegetables 

9  delicious 

1  groves 

5  nice 

1  result 

1  desire 

1  grow 

2  nutritious 

9  ripe 

1  watermelon 

1  digest 

1  grows 

2  nuts 

1  ripeness 

1  wine 

1  digestion 

2  growth 

562 


FREE  ASSOCIATION  TEST 


17.    BUTTERFLY 


1  air 

1  airiness 

2  airy 
24  animal 

2  animals 
2  ant 

1  beast 

24  beautiful 
20  beauty 
31  bee 

4  bees 

6  beetle 
64  bird 

10  birds 

2  black 

1  blossom 

1  bine 

2  bread 

1  bright 

2  brilliant 
1  brown 

1  bush 
8  butter 
6  buttercup 

11  bug 
1  bugs 

1  bumblebee 

1  cabbage 
87  caterpillar 
1  caterpillars 
1  chase 
8  chrysalis 


6  cocoon 

20  flying 

1  lilies 

I  soul 

1  cocoons 

1  little 

1  sparrow 

4  collection 

1  gaudy 

1  speckled 

12  color 

1  gauze 

1  meadows 

9  spider 

8  colors 

2  gay 

1  metamorphosis 

2  sjiotted 

3  colored 

2  girl 

4  miller 

5  spring 

2  country 

2  gnat 

1  monarch 

17  summer 

1  cricket 

3  golden 

3  mosquito 

1  sun 

1  good 

1  motion 

5  sunshine 

1  daisy 

2  grace 

30  moth 

1  swallow 

1  dish 

1  graceful 

1  moths 

1  sweet 

1  dove 

1  grass 

1  mountains 

1  swift 

1  dress 

5  grasshopper 

1  mourning  cloak 

1  dust 

2  grasshoppers 

1  temporaiy 

5  grub 

2  nature 

1  tree 

1  eagle 

6  net 

1  two 

1  ease 

1  handsome 

1  nets 

1  ephemeral 

1  happv 
1  high 

.     2  nice 

1  useless 

1  fairy 

1  horse 

1  orange 

2  vanity 

2  field 

1  human 

1  outdoors 

1  variegated 

1  fields 

1  firefly 

1  idler 

1  pancake 

11  wasp 

6  flies 

261  insect 

1  pig 

2  white 

2  flight 

2  insects 

2  pigeon 

1  wind 

1  flippant 

1  plumage 

11  wing 

1  flittering 

1  Japanese 

1  powder 

31  wings 

1  flitting 

39  pretty 

1  word 

1  flits 

1  kite 

12  worm 

13  flower 

1  red 

2  worms 

12  flowers 

1  lady 

2  flutter 

8  lepidoptera 

2  small 

87  yellow 

1  fluttering 

6  light 

1  snakes 

44  fly 

2  lightness 

1  snare 

18.    SMOOTH 


t  apple 

8  face 

Ikind 

6  pleasant 

2  small 

Ifair 

1  pleasing 

1  snake 

Iball 

1  feeling 

1  lake 

1  plum 

79  soft 

1  basin 

8  fine 

2  lawn 

5  polished 

1  softness 

2  bed 

2  finished 

1  lens 

1  pressed 

1  sphere 

9  board 

14  flat 

52  level 

1  stone 

1  butter 

2  flexible 

1  lightly 

1  quality 

2  straight 

15  floor 

1  lovely 

1  queer 

1  street 

4  calm 

1  folded 

1  stroke 

1  carpet 

2  fur 

1  machinery 

1  razor 

25  surface 

1  character 

1  mahogany 

2  river 

1  cheek 

56  glass 

10  marble 

4  road 

29  table 

1  chip 

4  glassy 

1  mercury 

1  roads 

1  thin 

1  circus 

1  glazed 

1  mild 

2  roof 

1  thought 

2  clean 

3  glide 

1  mirror 

277  rough 

1  tidy 

3  clear 

1  gliding 

1  molasses 

2  round 

1  tomato 

3  cloth 

11  glossy 

1  rubber 

1  tongue 

1  clothes 

2  good 

1  narrow 

1  rugged 

4  touch 

2  coarse 

1  goods 

4  nice 

1  rule 

1  tranquil 

1  coat 

1  grand 

1  nicely 

1  running 

1  country 

3  grass 

2  uneven 

1  course 

1  grease 

1  oyster 

1  sailing 

2  cream 

4  ground 

1  sandpapeu 

29  velvet 

1  cube 

1  paint 

2  satin 

1  velvety 

3  hair 

9  paper 

1  sea 

1  very 

1  deceitful 

2  hand 

2  paste 

1  shape 

1  deep 

41  hard 

1  pat 

1  sharp 

6  wall 

1  desk 

1  harmonious 

1  path 

1  shave 

1  walls 

1  done 

4  harsh 

1  pebble 

4  shiny 

10  water 

1  dry 

1  person 

4  silk 

1  wave 

14  ice 

1  piano 

1  silken 

1  window 

2  ease 

13  iron 

1  placid 

6  skin 

8  wood 

12  easy 

1  ironing 

17  plain 

2  sleek 

1  work 

80  ev(|n 

1  ivory 

23  plane 

3  slick 

1  worm 

1  evenness 

1  planed 

4  slippery 

1  vrrinkled 
I  wrinkles 

FREQUENCY  TABLES 


563 


19.     COMMAND 


1  ability 

1  dislike 

1  harshly 

12  obedience 

1  something 

1  act 

27  do 

1  haughty 

2  obedient 

8  speak 

1  acting 

3  doing 

1  head 

230  obey 

1  spoken 

1  anger 

2  domineei 

1  him 

1  obeyed 

1  stamina 

1  answer 

2  domineering 

1  holy 

30  officer 

1  statement 

1  anything 

2  done 

1  honorable 

1  only 

7  stern 

1  appeal 

1  appearance 

2  don't 

1  horse 

171  order 

3  strength 

1  door 

2  ordering 

1  strict 

16  army 

2  drill 

1  I 

9  orders 

3  strong 

1  arrogance 

1  driver 

1  immediately 

1  stubborn 

2  ask 

5  duty 

3  imperative 

1  parents 

1  superintend 

2  asking 

4  imperious 

1  peace 

1  superior 

1  athletics 

1  earnestness 

1  independent 

2  people 

1  supervisor 

3  attention 

1  easy 

1  insist 

2  peremptory 

1  surly 

14  authority 

1  eat 

1  instant 

1  perfect 

1  surrender 

1  effort 

1  institution 

1  person 

1  baseball 

1  employ 

2  instruct 

1  plead 

2  talk 

1  Bible 

1  employees 

1  instruction 

1  policeman 

1  teach 

1  bid 

1  enforce 

1  intelligence 

10  power 

14  teacher 

6  bosa 

1  entreat 

2  powerful 

1  teachers 

1  boy 

7  entreaty  _ 

1  judge 

1  praise 

1  teaching 

1  exclamation 

1  proper 

15  tell 

7  captain 

1  exertion 

1  knowing 

1  telling 

2  charge 
2  chief 

1  experience 

1  labor 

1  question 
1  quick 

3  temper 

1  temperament 

1  church 

1  father 

1  language 

1  thee 

1  combine 

1  firm 

2  law 

2  refuse 

1  them 

1  combined 

1  forbid 

1  laziness 

1  regiment 

2  think 

5  come 

7  force 

2  lead 

1  reply 

1  thinking 

5  commander 

1  forced 

1  leader 

2  reprimand 

1  thoughtfulncss 

2  commandment 

1  foreman 

1  lieutenant 

n  request 

1  threat 

2  company 

2  listen 

5  respect 

2  told 

1  compel 
8  control 
1  cross 

1  gain 
43  general 
1  gentleness 

2  loud 
1  love 

1  respond 
1  retreat 
8  right 

1  uncomfortable 
1  upright 

1  gently 

1  madam 

2  rule 

1  dare 

1  Germany 

9  man 

1  ruling 

6  voice 

IS  demand 

1  give 

2  master 

1  running 

1  vow 

1  demanding 

25  go 

1  masterful 

2  desire 

1  God 

3  military 

1  say 

1  wagon 

2  determined 

1  God's 

2  mind 

1  saying 

1  wife 

3  dictate 

2  good 

1  mother 

2  school 

3  will 

1  dictatorial 

1  govern 

1  move 

1  severe 

1  willing 

2  dignity 
2  direct 

1  grand 

1  miist 

1  Shalt 
1  ship 

2  words 
2  work 

1  disability 

4  halt 

1  noble 

16  soldier 

1  wrong 

2  discipline 

4  harsh 

1  nuisance 

6  soldiers 

5  vmi 

20.   CHAIR 


4  arm 

1  cushions 

1  idleness 

1  people 

56  sitting 

4  article 

1  implement 

3  person 

1  size 

9  desk 

1  place 

6  sofa 

1  back 

1  joiner 

1  placed 

5  soft 

1  beauty 

7  ease 

1  plant 

1  spooning 

1  bed 

6  easy 

3  large 

1  platform 

1  stand 

13  bench 

7    leg 

1  pleasant 

38  stool 

1  book 

1  fatigue 

11  legs 

1  pleasure 

1  stoop 

1  boy 

10  floor 

3  lounge 

1  posture 

1  study 

2  broken 

1  feet 

3  low 

1  support 

4  brown 

1  foot 

1  lunch 

1  reading 

1  bureau 

1  footstool 

45  rest 

191  table 

1  form 

3  mahogany 

3  resting 

1  tables 

3  cane 

83  furniture 

1  massive 

17  rocker 

1  talk 

1  caning 

1  mission 

15  rocking 

1  teacher 

^  careful 

1  Governor 

5  Morris 

9  room 

1  timber 

1  carpet 

Winthrop 

1  myself 

2  rounds 

1  tool 

1  cart 

1  rubber 

1  color 

1  hair 

2  necessity 

3  rung 

1  upholstered 

21  comfort 

5  hard 

1  upholstery 

8  comfortable 

2  hickory 

2  oak 

127  seat 

2  use 

3  convenience 

4  high 

1  object    , 

5  seated 

3  useful 

5  couch 

2  home 

1  occupy 

2  seating 

1  crooked 

3  house 

1  office 

3  settee 

1  white 

12  cuabioc 

107  sit 

49  wood 
6  wooden 

564 


FREE  ASSOCIATION  TEST 


6  agreeable 

1  dinner 

1  appetizing 

1  dog 

11  apple 

1  dreams 

3  apples 

1  E. 

3  beautiful 

2  eat 

60  bitter 

1  elegant 

1  black 

1  eyes 

1  breath 

1  face 

1  candies 

2  flavor 

82  candy 

2  flower 

1  cherries 

3  flowers 

1  child 

1  food 

3  chocolate 

1  fresh 

1  chocolates 

9  fruit 

2  clean 

1  confectionery 

1  gentle 

1  cream 

6  girl 

1  cunning 

26  good 

7  delicious 

2  harsh 

1  dessert 

12  honey 

21.  S^l^ICBT 

1  hunger 

33  nice 

1  sharp 

1  Huyler's 

I  sickish 

1  orange 

2  sixteen 

1  insipidity 

2  oranges 

6  soft 

1  soothing 

2  kiss 

9  palatable 

301  sour 

3  peach 

1  stuff 

1  limited 

1  peaches 

224  sugar 

1  lovely 

3  perfume 

2  syrup 

1  loving 

2  pie 

2  low 

1  plausible 

67  taste 

31  pleasant 

4  tasteful 

1  Mary 

i  pleasing 

2  tasting 

1  mellow 

1  pleasurable 

n  tasty 

1  melody 

1  pleasure 

1  tea 

2  milk 

1  plum 

2  toothsome 

1  molasses 

1  preserves 

1  mouth 

1  ugly 

8  music 

1  quality 

1  unpleasant 

1  musty 

1  saccharine 

1  very 

1  name 

3  salt 

1  voice 

1  nausea 

1  salty 

1  wholesome 

22.     "WHISTIiliJ 


1  act 

1  crow 

5  holler 

1  person 

1  sounds 

1  action 

2  cry 

1  hollow 

1  piercing 

3  steam 

7  air 

1  cuckoo 

4  horn 

7  pipe 

1  steamboat 

3  alarm 

1  humming 

2  pleasure 

1  stick 

1  annoyance 

3  dance 

1  police 

2  attention 

1  dear 

6  instrument 

6  policeman 

4  talk 

1  automobile 

1  disagreeable 

1  postman 

1  telephone 

1  distant 

2  joy 

1  postman's 

1  throat 

1  bad 

7  dog 

1  pretty 

7  tin 

2  bell 

1  drink 

1  lad 

4  pucker 

1  tool 

15  bird 

1  dumb 

3  laugh 

1  top 

3  birds 

1  letter-carrier 

1  quiet 

4  toy 

1  blast 

1  ear 

6  lips 

6  train 

5  blew 

3  echo 

5  locomotive 

2  racket 

I  tree 

95  blow 

1  effort 

3  long 

1  report 

2  trumpet 

6  blowing 

15  engine 

27  loud 

1  running 

18  tune 

2  blows 

1  low 

2  boat 

2  factory 

1  scream 

1  umpire 

66  boy 

3  flfe 

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5G5 


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566 


FREE  ASSOCIATION  TEST 


25c   SLOW^ 

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26.  WISH 

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567 


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568 


FREE  ASSOCIATION  TEST 


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29.    BEAUTIi'UL 

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1  girl 

6  mountain 

7  rude 

4  uncomfortable 

1  brutality 

1  granite 

1  mountains 

1  rudeness 

4  uncouth 

1  bumpy 

1  granular 

1  rug 

1  uneasy 

1  grater 

1  nice 

22  rugged 

38  uneven 

2  calm 

1  grating 

1  noisy 

1  ruggedness 

1  unfairness 

1  careless 

1  gravel 

1  Russian 

1  unfinished 

2  carpet 

8  ground 

1  obstetricians 

1  rut 

7  unpleasant 

1  chaps 

27  ocean 

1  unsatisfactory 

4  cloth 

1  hairy 

1  orange 

5  sand 

1  untaught 

29  coarse 

Ihall 

13  sandpaper 

1  coarseness 

2  hapd 

1  papei 

1  savage 

1  voices 

1  cobblestones 

38  hard 

1  pavement 

15  sea 

2  voyage 

1  cold 

1  hardness 

1  peasant 

1  sedate 

5  vulgar 

2  country 

10  harsh 

1  pebbles 

1  scratch 

2  crooked 

1  harshness 

2  person 

1  shock 

2  walk 

1  cross 

1  haste 

1  picture 

1  sliver 

1  wall 

1  cruel 

2  hill 

1  pineapple 

1  slow 

1  washing 

2  hills 

2  plane 

346  smooth 

21  water 

1  desert 

5  hilly 

1  plank 

3  smoothness 

5  waves 

1  diflacult 

1  horrid 

1  play 

4  soft 

1  weary 

1  dirt 

1  house 

1  poor 

1  sponge 

4  weather 

3  disagreeable 

1  porcupine 

1  stem 

1  west 

X  discomfort 

Sice 

1  push 

1  sticky 

2  wild 

1  discouraging 

1  impertinent 

12  stone 

2  wind 

1  dog 

1  injurious 

1  quality 

8  stones 

1  winds 

1  dress 

2  iron 

1  quiet 

7  stony 

7  wood 

3  dry 

2  irregular 

1  quite 

5  storm 

1  woodsman 

1  dull 

■     1  stormy 

1  work 

1  jagged 

1  radiator 
32.   CITIZEN 

1  straight, 

1  world 
1  wrong 

14  alien 

1  commander 

1  fine 

1  inhabit 

2  men 

5  America 

3  community 

2  five 

23  inhabitant 

1  merry 

S5  American 

1  comrade 

1  fool 

1  invader 

1  moral 

3  Americans 

1  conspirators 

1  foreign 

1  Italian 

1  Mr.  A. 

1  army 

1  constitution 

19  fuieigner 

1  Mr.    0.. 

1  arrived 

r  cosmopolitan 

I  free 

2  justice 

1  Mr.    S. 

1  countrified 

2  freeman 

1  municipal 

4  belong 

17  country 

1  friend 

1  K. 

1  myself 

1  belonging 

7  countryman 

1  friendship 

1  king 

1  beloved 

1  criticise 

1  name 

1  beneficial 

1  gardener 

1  large 

1  nationality 

1  bird 

1  democrat 

8  gentleman 

11  law 

25  native 

3  bom 

2  duties 

3  German 

1  laws 

1  natural 

1  Brooklyn 

3  duty 

26  good 

3  lawyer 

1  naturalization 

1  brother 

1  dweller  . 

6  government 

1  leader 

5  naturalized 

1  business 

1  dwelling 

1  green 

1  leading 
1  legislature 

1  navy 
1  near 

IC. 

1  ear 

1  helper 

1  Lincoln 

3  neighbor 

1  candidate 

1  election 

3  home 

1  little 

1  newspaper 

1  capital 

1  eligible 

2  honest 

1  live 

4  New  York 

1  cat 

2  emigrant 

1  honor 

1  lives 

1  noble 

1  cistern 

1  emigration 

2  honorable 

3  loyal 

2  nobleman 

1  citizeness 

3  human 

1' nonsense 

27  city 

IP. 

7  male 

4  civics 

1  faithful 

11 

278  man 

1  obedient 

2  civilian 

1  farm 

1  immigrant 

1  manhood 

1  obey 

4  civilized 

3  farmer 

1  independence 

6  mayor 

1  occupant 

1  clothes 

3  fellow 

1  Indian 

1  me 

2  oflice 

Iclub 

2  fellowship 

4  individual 

5  member 

1  officer 

570 


FREE  ASSOCIATION  TEST 


1  old 

4  politician 

1  righteousness 

1  suburban 

1  unit 

1  orderly 

1  politicians 

2  Roman 

3  suffrage 

19  United    States 

I  outlaw 

8  politics 
1  poor 

2  Roosevelt 
1  ruler 

2  suffragette 

2  useful 

2  paper 

4  president 

3  Taft 

2  village 

2  papers 

1  proud 

1  season 

1  Tammany 

13  vote 

1  patrician 

1  ship 

1  taxes 

4  voting 

2  patriot 

1  relative 

5  soldier 

1  Teddy 

35  voter 

2  patriotic 

3  republic 

10  state 

1  thoughtful 

1  peasant 

1  republican 

5  statesman 

1  tough 

1  Washington 

41  people 

2  residence 

1  stationed 

5  town 

2  woman 

64  person 

20  resident 

1  straight 

5  townsman 

2  work 

1  plebeian 

1  respectable 

5  subject 

2  policeman 

1  revolution 

33.  FOOT 

2  undesirable 

1  years 

2  anatomy 

1  finger 

1  labor 

1  pedant 

1  standard 

2  animal 

1  firm 

1  lame 

1  pedestal 

6  step 

11  ankle 

1  flat 

14  large 

1  pedestrian 

1  stepping 

2  appendage 

6  flesh 

54  leg 

5  person 

2  stocking 

11  arm 

1  football 

1  legs 

1  plaster 

1  stone 

3  foundation 

2  length 

1  strength 

1  baby'e 

58  limb 

2  quadruped 

1  strong 

1  base 

1  gear 

2  long 

1  stumps 

1  bicycle 

1  girls 

1  rheumatism 

1  support 

2  big 

1  going 

6  man 

1  right 

1  swiftness 

3  black 

1  good 

3  measure 

1  rubber 

34  body 

2  ground 

10  member 

4  rule 

1  three 

4  bone 

1  mine 

1  ruler 

5  tired 

5  bonea 

185  hand 

1  Miss  F. 

2  run 

30  toe 

6  boot 

5  hands 

2  movement 

41  toes 

1  bottom 

7  head 

1  music 

1  shape 

2  travel 

1  broken 

3  heel 

146  shoe 

1  trod 

1  brown 

1  help 

1  nail 

17  shoes 

1  twelve 

1  helper 

1  naked 

4  short 

1  two 

1  careful 

1  horse 

2  necessity 

1  size 

3  comfort 

1  house 

1  needful 

1  skin 

6  useful 

3  com 

1  human 

2  slipper 

2  corns 

1  humility 
1  hurt 

1  organ 

22  small 
1  sole 

1  velocity 

1  dainty 

1  pain 

8  sore 

106  walk 

1  difficult 

3  inch 

1  painful 

1  speed 

38  walking 

I  distance 

2  inches 

2  part 

1  pavement 

1  stability 
6  stand 

1  warm 

1  expansive 

4  kick 

3  pedal 

1  standing 

1  yard 

9  extremity 

2  knee 

34.    SPIDXIR 

1  abhorrence 

1  crawls 

4  flies 

3  nasty 

1  stung 

1  afraid 

11  crawling 

136  fly 

1  nest 

1  study 

38  animal 

1  crawly 

1  fright 

2  net 

1  annoyance 

2  creature 

1  fry 

1  nuisance 

3  tarantula 

3  ant 

6  creep 

1  frying 

1  thing 

2  arachnida 

1  creeps 

1  objectionable 

2  thread 

1  arachnoid 

7  creeping 

1  grass 

1  obnoxious 

1  tortoise 

1  awful 

1  creepiness 

I  octopus 

1  treachery 

5  creepy 

1  harlequin 

1  tree 

3  bee 

2  cricket 

1  harmful 

1  pain 

2  bees 

1  cringe 

1  horrible 

1  pan 

6  ugly 

4  beetle 

1  cross 

4  horrid 

1  pest 

1  tmdesirable 

1  big 

1  crow 

3  horror 

10  poison 

1  unpleasant 

2  bird 

1  cunning 

1  poisonous 

20  bite 

1  industry 

1  pretty 

2  venomous 

8  black 

1  daddy-long- 

276 insect 

1  vermin 

1  breakfast 

legs 

1  rats 

58  bug 

1  danger 

1  jumping 

2  Robert    Bruce 

1  walk 

2  bugs 

4  dangerous 

1  roach 

1  wall 

5  butterfly 

2  dark 

5  large 

1  room 

6  wasp 

1  dirty 

3  leg 

1  watching 

1  camp 

3  disagreeable 

27  legs 

1  shivers 

2  weaves 

3  caterpillar 

1  displeasure 

1  loathsome 

1  shudder 

1  weaving 

1  centipede 

1  dread 

1  long 

1  sinister 

188  web 

1  chills 

2  small 

3  webs 

1  climb 

1  evil 

1  Miss   Muffet 

1  snake 

1  wiggly 

12  cobweb 

1  mosquito 

1  snakes 

4  worm 

2  cobwebs 

3  fear 

1  moth 

1  sparrow 

1  country 

1  fish 

1  movements 

7  sting 

1  young 

14  crawl 

1  stings 

FREQUENCY  TABLES 


571 


35.     NEBDIiS: 

3  article 

2  dressmaker 

4  kiutting 

1  pincushion 
49  point 

1  stitching 
1  surgeon 

1  blond 

1  embroidery 

1  labor 

9  pointed 

2  book 

17  eye 

1  long 

10  prick 

1  tailor 

1  broken 

1  pricks 

2  thick 

1  button 

3  fine 

1  magnetic 

2  pricking 

15  thimble 

1  buttons 

1  material 

2  thin 

1  handy 

1  mending 

134  Bew 

160  thread 

1  camel 

1  help 

3  metal 

1  sewa 

5  tool 

4  cloth 

1  hole 

107  sewing 

2  clothes 

1  home 

1  nail 

152  sharp 

1  use 

2  coat 

1  housewife 

4  sharpness 

1  using 

7  cotton 

2  hurt 

1  ornament 

1  shiny 

12  useful 

1  crocheting 

2  hypodermic 

1  slippers 

1  cut 

1  patching 

2  small 

1  weapon 

5  implement 

147  pin 

63  steel 

1  wire 

4  darning 

2  industry 

11  pins 

2  sting 

1  woman 

1  diligence 

26  instrument 

36.   RKD 

6  work 

1  apprravating 

1  cheeks 

1  fright 

1  jacket 

2  rug 

1  anarchist 

1  cheer 

2  flower 

2  anger 

1  cherries 

1  flowers 

1  lavender 

3  scarlet 

13  apple 

1  closet 

1  flushing 

1  light 

1  shoe 

3  apples 

8  cloth 

1  lips 

2  sky 

1  clouds 

1  garment 

1  smooth 

1  ball 

2  coat 

3  garnet 

1  maroon 

1  soldier 

1  banner 

254  color 

1  gaudy 

1  Mars 

1  spots 

2  barn 

1  colors 

2  glaring 

1  mixture 

1  story 

2  beauty 

1  colored 

1  glass 

1  moon 

6  sun 

1  becoming 

1  coloring: 

1  globe 

3  sunset 

61  black 

1  comfortable 

1  glow 

1  object 

1  sweater 

71  blood 

1  Cornell 

1  grass 

1  objectionable 

1  bloody 

1  cow 

30  green 

1  offensive 

1  tablecloth 

1  blossom 

2  crimson 

1  orange 

4  thread 

99  blue 

2  curtain 

6  hair 

1  tie 

8  book 

1  handsome 

5  paint 

1  tomatoes 

1  bravery 

14  danger 

1  hat 

4  paper 

2  turkey 

3  brick 

6  dark 

2  head 

1  passion 

2  bricks 

1  dashy 

1  healthy 

1  pencil 

1  vivid 

40  bright 

1  dislike 

4  heat 

1  pink 

2  brightness 

18  dress 

1  Hereford 

1  plush 

1  war 

3  brilliant 

1  holly 

1  poinsettia 

6  warm 

1  brook 

1  eat 

1  hood 

2  pretty 

3  warmth 

7  brown 

1  Ed 

1  horse 

6  purple 

1  whiskey 

1  building 

5  hot 

97  white 

2  bull 

2  fiery 

2  house 

2  ribbon 

1  wool 

31  fire 

1  riding 

1  world 

1  cap 

16  flag 

2  Indian 

2  robin 

1  eape 

3  flannel 

4  ink 

15  rose 

1  yam 

1  carpet 

1  flashy 

1  iron 

2  rosy 

15  yellow 

1  ceiling 

37.   SLE^EP 

94  awake 

2  dead 

4  eat 

1  habit 

1  midnight 

1  awaking 

7  death 

1  enjoyable 

1  happiness 

1  myself 

3  awaken 

5  deep 

1  enjoyment 

3  health 

1  awakening 

1  desire 

1  enough 

1  heavy 

1  natural 

1  desperate 

1  experiment 

1  home 

4  necessary 

2  baby 

1  dope 

10  eyes 

1  need 

1  beautiful 

2  dormitory 

2  insomnia 

1  needful 

75  bed 

1  dose 

1  fast 

1  nice 

1  bedstead 

4  doze 

2  fatigue 

1  lady 

49  night 

28  dream 

1  fine 

1  leisure 

2  calm 

10  dreams 

2  forgetfulness 

1  lain 

.   1  peace 

1  chance 

6  drowsy 

3  lie 

1  peaceful 

2  child 

3  drowsiness 

1  gentle 

1  lying 

2  peacefulnes 

1  children 

1  dullness 

1  girl 

1  luxurious 

1  perfect 

1  coma 

1  go 

1  luxury 

5  pillow 

30  comfort 

3  ease 

5  good 

3  pleasant 

4  easy 

1  mesmerism 

1  plenty 

572 


FREE  ASSOCIATION  TEST 


1  poorly 

2  refreshment 

1  senses 

1  song 

60  wake 

1  potassium    bro- 

1 relax 

1  Shakespeare 

2  soothing 

4  wakefulness 

mide 

31  repose 

1  sheet 

16  sound 

1  wakened 

2  profound 

300  rest 

1  shut 

3  soundly 

1  wakening 

14  resting 

1  silence 

2  still 

4  waking 

8  quiet 

9  restful 

1  sleeplessness 

3  sweet 

2  walk 

2  quietness 

4  restless 

1  sleepy 

1  wanting 

1  quietude 

1  restore 

20  slumber 

1  thinking 

1  watchful 

2  restorer 

2  slumbering 

26  tired 

3  weariness 

1  rage 

1  retiring 

4  snore 

1  tiresome 

1  weary 

2  recline 

1  rise 

1  soft 

1  well 

1  reclining 

1  rising 

1  solace 

12  unconscious 

1  woman 

7  refreshing 

38.   ANGER 

7  unconsciousness 

1 

1  abuse 

5  disturbed 

1  horror 

1  nonsense 

1  slow 

1  aggravated 

4  dog 

3  hot 

1  not 

2  smooth 

2  aggravation 

1  downhearted 

1  hot-headed 

1  noticeable 

1  sober 

1  agony 

1  duel 

1  house 

1  soft 

2  amiability 

1  humor 

1  obey 

1  soldier 

1  amiable 

3  emotion 

1  hunger 

1  out 

1  sometimes 

6  angry 

2  enemy 

1  hysteria 

1  outrage 

1  soothing 

2  anguish 

1  energy 

10  sorrow 

1  annoyance 

1  enmity 

1  01 

1  pain 

1  spite 

3  annoyed 

1  excitability 

4  impatience 

51  passion 

1  spiteful 

1  appearance 

3  excited 

3  impatient 

1  passionate 

1  storm 

1  aroused 

4  excitement 

1  Indian 

3  patience 

1  strike 

1  awful 

1  exclamation 

1  indignant 

6  peace 

1  strong 

2  indignation 

1  peaceful 

1  suffering 

13  bad 

1  face 

1  insanity 

1  peevish 

1  sulky 

2  bitter 

1  father 

1  insult 

2  person 

1  swear 

3  bitterness 

9  fear 

1  insulted 

1  placid 

1  sweetness 

1  blow 

4  feeling 

1  intense 

5  pleasant 

1  sword 

1  blows 

1  ferocity 

1  intensity 

4  pleasure 

1  blush 

1  fierce 

1  intoxication 

2  provocation 

1  talking 

3  boy 

1  fiery 

2  ire 

1  provoke 

2  teacher 

1  breathing 

8  fight 

1  irritable 

1  provoked 

1  tears 

1  fighting 

2  provoking 

149  temper 

7  calm 

1  fist 

1  jealousy 

1  temperament 

1  calmness 

1  flush- 

1  Jimmy 

3  quarrel 

1  terrible 

2  cat 

1  foolish 

4  joy 

2  quarreling 

1  terror 

1  catching 

3  foolishness 

1  joyful 

1  quarrelsome 

3  thought 

2  cause 

1  force 

1  judgment 

4  quick 

1  torment 

1  character 

1  forgive 

1  quickness 

6  trouble 

1  cheer 

3  forgiveness 

2  kind 

6  quiet 

1  turbulent 

1  child 

1  frenzy 

2  kindness 

1  quietness 

1  turmoil 

1  children 

1  fret 

1  quite 

1  choler 

1  fright 

1  laughter 

1  ugliness 

1  cold 

1  frown 

1  light 

16  rage 

4  ugly 

3  command 

1  frowning 

2  lion 

1  rarely 

1  unbecoming 

1  compose 

1  fun 

1  little 

1  rashly 

1  uncomfortable 

5  control 

2  furious 

3  loud 

1  rashness 

1  unhealthy 

1  coot 

4  fury 

5  love 

1  raving 

4  unpleasant 

1  cranky 

1  low 

1  reason 

1  crazy 

2  gentle 

3  red 

1  very 

44  cross 

3  gentleness 

121  mad 

1  remorse 

3  vexation 

2  crossness 

1  giant 

1  maddest 

2  resentment 

13  vexed 

1  covetous 

1  girl 

19  madness 

1  resistive 

1  vicious 

1  cruel 

4  glad 

2  malice 

1  rest 

1  violence 

1  cry 

2  gladness 

6  man 

1  restless 

2  violent 

2  good 

1  mean 

8  revenge 

1  voice 

1  danger 

1  great 

4  meekness 

2  riled 

1  deliberation 

3  grief 

1  mild 

3  rough 

1  war 

1  despise 

1  grieve 

4  mind 

1  roughness 

5  wicked 

1  devil 

2  grouchy 

2  mirth 

1  rude 

1  wickedness 

4  disagreeable 

2  myself 

1  wish 

1  disappointed 

4  happiness 

1  sad 

2  disappointment    2  happy 

1  name 

2  scold 

4  woman 

S  discomfort 

3  harsh 

1  nature 

2  scolding 

1  words 

1  dishonor 

2  haste 

1  nerves 

1  scowl 

52  wrath 

1  dislike 

3  hasty 

1  nervous 

1  sedative 

1  wrathful 

1  disobedience 

9  hate 

1  never 

1  selfishness 

2  wroth 

1  disflhedient 

1  hateful 

1  nice 

1  sharp 

4  wrong 

2  displeased 

26  hatred 

2  noise 

1  shorn 

2  disnieasure 

1  headache 

1  noisy 

1  sick 

1  yelling 

3  disturbance 

1  horrid 

1  none 

1  sin 

FREQUENCY  TABLES 


573 


39.  CARPET 


1  appearance 

1  curtains 

8  green 

1  pattern 

10  sweeper 

1  article 

1  pennant 

1  dark 

1  hall 

1  pleasant 

1  table 

1  beat 

6  design 

3  heavy 

2  plush 

8  tack 

2  beating 

1  designer 

4  home 

4  pretty 

3  tacks 

1  beater 

2  dirt 

4  house 

2  protection 

2  tapestry 

2  beautiful 

1  down 

2  textile 

1  beautifying 

1  drag 

2  ingrain 

1  quick 

2  thread 

2  beauty 

1  dullness 

2  tread 

1  bedroom 

4  dust 

1  lay 

7  rag 

2  blue 

1  duster 

1  loom 

3  rags 

2  use 

2  bright 

1  lot 

1  ragged 

1  useful 

1  broom 

3  ease 

3  luxury 

8  red 

2  brown 

1  electric 

1  reddish 

9  velvet 

1  brush 

1  expense 

6  mat 

1  refinement 

1  brushes 

3  material 

1  rich 

15  walk 

14  Brussels 

2  fancy 

10  matting 

17  room 

6  walking 

3  figure 

1  mattress 

2  rough 

1  wall 

1  chair 

1  flat 

1  microbes 

163  rug 

1  Wanamakei 

1  chairs 

6  floor 

1  moss 

14  rugs 

2  warm 

3  clean 

2  floorii 

5  warmth 

2  cleaning 

2  foot 

1  nail 

1  shoes 

1  weaver 

1  cleaner 

1  fur 

1  neatness 

1  small 

1  weaving 

20  cloth 

1  furnishing 

2  nice 

8  smooth 

1  wear 

6  color 

4  furniture 

1  none 

78  soft 

1  white 

1  colors 

4  softness 

1  wide 

15  comfort 

1  germs 

7  oilcloth 

2  stairs 

1  wood 

S  comfortable 

2  good 

1  oriental 

1  stove 

10  wool 

2  cotton 

4  goods 

2  ornament 

1  straw 

7  woolen 

27  cover 

1  grain 

7  sweep 

1  worsted 

76  covering 

1  gray 

8  parlor 
40.  GIRIi 

3  sweeping 

2  woven 

1  ankles 

2  cute 

3  hair 

7  maid 

6  sister 

1  Annie 

1  hand 

13  maiden 

2  sixteen 

1  associate 

2  dainty 

5  handsome 

1  maidenb 

1  skirts 

1  damsel 

1  happiness 

1  male 

1  slender 

1  baby 

1  dance 

1  harmlessness 

7  man 

1  slight 

1  Beatrice 

1  dancing 

1  has 

1  men 

1  slim 

8  beautiful 

2  daughter 

3  hat 

1  meek 

8  small 

6  beauty 

1  delight 

1  head 

1  mischiev 

1  smart 

9  being 

1  diabolo 

1  here 

4  miss 

1  smartness 

1  belt 

1  domestic 

1  hood 

1  Miss  S. 

1  student 

1  big 

1  Doris 

1  hoop 

1  modesty 

1  studious  ■ 

1  biped 

1  Dorothy 

7  human 

2  mother 

3  study 

1  blonde 

1  dream 

1  humanity 

2  myself 

1  sfvlish 

1  blooming 

8  dress 

1  summer 

1  book 

4  dresses 

1  immature 

2  neat 

4  sweet 

350  boy 

2  infant 

2  necessity 

1  sweetness. 

3  boys 

1  Effie 

3  innocence 

11  nice 

2  sweetheart 

2  braids 

1  Ethel 

1  innocent 

2  niece 

1  bright 

1  eyes 

1  intelligent 
1  Irene 

1  noise 

1  talks 
4  tall 

1  changeable 

1  fair 

1  Pelar 

1  thoughtless 

1  cheerful 

2  fellow 

1  jealousy 

IS  person 

49  child 

77  female 

2  jolly 

1  petticoats 

1  ugly 

2  children 

3  feminine 

2  joy 

2  play 

1  useful 

2  childhood 

3  flesh 

4  pleasure 

1  childish 

1  flirtation 

1  kid 

29  pretty 

1  vanity 

1  choice 

1  Frances 

1  pupil 

2  virgin 

1  class 

7  friend 

20  lady 

1  classmate 

1  futurity 

1  large 

1  quick 

1  walk 

1  clever 

1  lassie 

1  rarely 

1  water 

4  clothes 

1  garden 

1  learning 

1  running 

2  weak 

1  clothing 

1  gay 

S  little 

1  white 

1  Coleen 

1  gentility 

1  lively 

1  saucy 

1  wife 

1  college 

1  gentle 

1  Lizzie 

19  school 

61  woman 

2  companion 

1  Gertrude 

3  love 

3  servant 

1  cook 

6  good 

1  loving 

4  sex 

31  young 

1  cunning 

1  grace 

4  lovely 

1  shirk 

1  yoimgster 

2  cwls 

4  silly 

24  youth 

574 


FREE  ASSOCIATION  TEST 


41.  HIGH 

9  above 

2  dizzy 

24  house 

16  mountains 

1  staff 

5  air 

1  houses 

1  myself 

1  stand 

1  Alps 

11  elevated 

13  steep 

14  altitude 

2  elevation 

1  ideal 

1  notion 

12  steeple 

1  ascend 

1  erect 

1  ideas 

1  stick 

2  exalted 

1  immense 

4  peak 

1  stone 

1  bank 

1  extended 

1  pine 

1  summit 

1  beam 

2  jump 

1  pinnacle 

2  swing 

1  beanstalk 

3  fall 

1  play 

SbifT 

2  falling 

1  kite 

8  pole 

57  tall 

1  bridge 

1  far 

2  ladder 

1  power 

1  temperature 

24  building: 

1  fast 

5  large 

3  precipice 

1  temple 

2  buildings 

2  fear 

7  length 

5  top 

1  feet 

1  lighthouse 

2  reach 

12  tower 

1  Cathedral 

8  fence 

20  lofty 

1  rich 

19  tree 

4  ceiling 

1  first 

7  long 

1  rocky 

4  trees 

2  chair 

328  low 

3  roof 

2  church 

2  giant 

1  room 

26  up 

1  cliff 

1  gre^t 

1  magnificent 

1  upward 

1  climb 

1  man 

1  see 

1  climbing 

1  hat 

2  mast 

1  shallow 

1  valley 

7  clouds 

1  heaven 

1  measure 

3  short 

1  vision 

3  heavens 

3  medium 

1  skies 

5  deep 

1  heavenward 

1  Metropolitan 

17  sky 

5  wall 

4  depth 

14  height 

1  mind 

2  skyscraper 

1  waves 

1  dimension 

20  hill 

2  monument 

1  small 

2  wind 

11  distance 

4  hills 

1  mount 

1  soft 

1  woman 

3  distant 

1  hot 

157  mountain 

1  spire 

43.    WORKING 


1  accomplish 

2  earning 

2  horse 

1  accomplishment 

2  ease 

1  hour 

3  active 

1  easiness 

1  house 

1  activity 

4  easy 

1  always 

2  eating 

44  idle 

1  ambition 

1  effort 

10  idleness 

5  ambitious 

10  employed 

2  idling 

1  anxious 

1  employers 

1  inconvenience 

1  apron 

4  employment 

1  indolent 

1  attendant 

2  energetic 

13  industrious 

3  energy 

8  industry 

1  bent 

2  engaged 

1  intelligent 

1  book 

1  English 

1  interest 

2  boy 

1  essay 

2  Italian 

2  broom 

15  exercise 

1  job 

6  business 

1  exercising 

61  busy 

S  exertion 

1  keeping 

1  carpenter 

3  factory 

147  labor 

3  class 

2  fair 

20  laboring 

1  comfort 

1  faithfully 

1  labors 

1  complication 

1  farm 

5  laborer 

2  content 

1  fast 

1  lack 

2  continually 

3  father 

1  ladies 

1  continuous 

7  fatigue 

1  late 

1  cooking 

2  fatigued 

2  laziness 

1  field 

18  lazy 

6  day 

1  flowers 

1  leisure 

1  difficult 

1  foundry 

1  Lillie 

1  dipreing 

1  function 

1  little 

1  diligence 

1  live 

1  discomfort 

2  girl 

2  livelihood 

2  do 

4  good 

5  living 

10  doing 

1  loaf 

1  done 

2  hammer 

5  loafing 

1  drawing 

3  hands 

1  loafer            , 

1  driving 

1  happiness 

1  lounging 

1  drudge 

105  hard 

1  dusting 

2  health 

2  machine 

1  duties 

1  healthy 

1  machinery 

2  duty 

1  hoeing 

1  machinist 

1  making 

50  man 
6  men 
1  model 

4  money 

1  morning 

3  motion 

2  movement 

5  moving 

1  mowing 

2  myself 

4.  necessary 
1  necessity 
1  neii^hbor 
1  never 
1  night 
1  noble 
1  nothing 
1  nursing 

1  obstetrics 
13  occupation 
1  occupied 

1  occupy 

2  order 

1  paid 

1  patients 
5  people 

2  person 

1  perspiration 
8  play 
22  playing 
1  pleasant 

4  pleasure 
1  plow 

1  plowing 
1  policy 
1  position 
1  possession 


1  prosperous 
1  quick 

1  railroad 

1  reading 

1  recreation 
17  rest 
24  resting 

1  result 

1  rowing 

3  running 

1  salary 

1  satisfaction 

1  saving 

6  school 

3  scrubbing 

2  servant 

1  setting 

7  sewing 

2  shirking 

7  shop 

1  shorthand 
1  sickness 
1  singing 

3  sitting 

4  slave 

1  slavery 

1  slaving 

2  sleep 

8  sleeping 
1  slow 

1  smart 

1  starving 

2  steady 

1  stenographed" 

2  strenuous 
1  struggle 

5  study 

6  studying; 


FREQUENCY  TABLES 


575 


1  sweep 

1  thought 

9  toiling 

2  unemployed 

1  weariness 

3  sweeping 

1  time 

2  tools 

2  useful 

2  willing 

1  swift     - 

28  tired 

1  treadmill 

2  woman 

3  tiresome 

1  trouble 

4  W2ge3 

1  work 

1  table 

1  tiring 

2  trying 

2  walking 

1  workman 

2  task 

1  to-day 

1  typewriter 

1  washerwoman 

1  world 

1  thinking 

7  toil 

43.  SOUR 

5  washing 

2  writing 

1  acetic 

1  delight 

1  juice 

15  pickle 

1  stomach 

23  acid 

18  disagreeable 

26  pickles 

2  sugar 

1  acrid 

1  dislike 

2  kraut 

1  pleasant 

349  sweet 

1  anger 

3  disposition 

1  plum 

1  angry 

4  distasteful 

78  lemon 

1  plums 

17  tart 

27  apple 

1  drink 

17  lemons 

3  pucker 

65  taste 

10  apples 

1  lime 

2  tasting 

1  astringent 

1  face 

3  quince 

2  tasteless 

1  flavor 

1  man 

1  teeth 

6  bad 

3  fruit 

Si  milk 

1  rancid 

1  turned 

1  beer 

1  repulsive 

1  twinge 

70  bitter 

1  gall 

3  nasty 

5  rhubarb 

1  bitterness 

4  good 

1  naturally 

1  rough 

4  ugly 

1  goodness 

3  nice 

1  unhappy 

3  cherries 

3  grape 

1  no 

2  salt 

3  unpalatable 

2  cider 

36  grapes 

1  nourishing 

1  salty 

16  unpleasant 

1  cross 

2  grapefruit 

2  sauerkraut 

1  unpleasantness 

I  crowd 

1  green 

1  odor 

1  sear 

1  unsweetened 

1  currants 

2  orange 

2  sharp 

1  hate 

1  soft 

01  vinegar 

1  dangerous 

1  hurts 

1  painful 

1  song 

1  death 

1  persimmon 
44.  SARTH 

1  spoiled 

1  wholesome 
1  wine 

1  agriculture 

115  dirt 

1  growth 

2  mould 

5  sand 

3  air 

4  dirty 

1  mouldy 

31  sky 

1  ashes 

1  dogs 

2  habitation 

4  mountain 

1  smelly 

4  dry 

4  hard 

2  mountains 

3  smooth 

4  ball 

9  dust 

31  heaven 

16  mud 

2  sod 

3  beautiful 

1  heavens 

5  soft 

2  big 

3  farm 

2  heavy 

4  nature 

37  soil 

7  black 

1  farming 

1  hell 

1  solid 

1  body 

1  fence 

1  hemisphere 

1  object 

2  solidity 

2  broken 

1  fertile 

3  home 

1  ocean 

1  space 

17  brown 

1  fertilized 

1  house 

1  one 

4  sphere 

1  building 

i  field 
1  fields 

1  huge 

1  orange 

1  star 

2  stone 

1  cemetery 

1  flag 

1  inhabitable 

1  paradise 

2  stones 

71  clay 

3  floor 

I  place 

1  street 

1  climate 

1  flower 

28  land 

17  planet 

1  substance 

1  cloud 

8  flowers 

7  large 

2  plant 

4  sun 

1  cofliin 

1  foot 

1  level 

5  plants 

3  surface 

2  cold 

1  foundation 

3  live 

1  planting 

1  color 

1  fresh 

2  living 

1  pleasure 

1  travel 

2  Columbus 

1  fruitful 

3  loam 

1  potential 

4  tree 

1  continent 

1  Fuller's 

1  lot 

1  productive 

5  trees 

2  corn 

2  low 

1  put 

2  country 

8  garden 

1  unfertile 

1  cover 

1  geranium 

1  man 

1  rain 

8  universe 

1  creation 

16  globe 

2  map 

1  rampart 

1  crunching 

2  grain 

3  Mars 

1  rest 

1  vastneas 

1  crushed 

1  grand 

1  mass 

1  revolution 

1  vegetable 

6  crust 

11  grass 

1  material 

4  rich 

3  grave 

1  matter 

1  river 

3  walk 

6  damp 

2  gravel 

1  metal 

1  road 

10  water 

10  dark 

1  gravity 

1  mine 

2  rock 

1  wide 

1  delve 

2  great 

1  mineral 

2  rocks 

1  wood 

2  depth 

3  green 

3  moist 

61  round 

46  world 

1  dig 

1  greenhouse 

11  moon 

1  ro'ir.dnesa 

5  worm 

2  digging 

166  ground 

0  mother 

2  worms 

576 


FREE  ASSOCIATION  TEST 


45.  TROUBIii: 


8  accident 

1  disagreeable 

3  health 

20  pain 

1  table 

4  afiBiction 

2  disagreement 

1  heart 

2  patience 

1  task 

3  aggravation 

1  disappoint 

1  heaviness 

2  patient 

9  tears 

6  anger 

3  disaster 

1  hemorrhage 

1  patients 

1  teasing 

6  angry 

7  discomfort 

2  home 

15  peace 

1  temper 

1  anguish 

2  discontent 

1  horror 

3  peaceful 

1  temptation 

1  annoy 

3  disease 

1  horse 

3  people 

2  thought 

2  annoyed 

2  dislike 

1  hurried 

1  perplexed 

1  thoughts 

5  annoyance 

1  disobedience 

1  husband 

1  perplexity 

1  torment 

15  anxiety 

1  displeased 

?  person 

1  travel 

2  avoid 

1  displeasing 

1  idea 

1  pity 

1  trial 

2  displeasure 

2  illness 

10  pleasure 

3  trials 

31  bad 

1  dissatisfactory 

1  imaginary 

1  plenty 

6  troublesome 

1  begins 

7  distress 

2  inconvenience 

2  poor 

1  black 

2  disturbed 

2  poverty 

1  ugly 

1  borrowea 

1  doctor 

9  joy 

1  psychologist 

1  unavoidable 

1  borrows 

1  dogs 

1  uncertainty 

4  bother 

1  kindness 

3  quarrel 

2  uncomfortable 

2  bothered 

4  ease 

1  kinds 

3  quarreling 

6  uneasiness 

1  botherBome 

1  easiness 

3  quiet 

6  uneasy 

1  brains 

1  easy 

1  labor 

1  quietness 

2  unfortunate 

1  brewing 

1  ended 

1  laugh 

13  unhappiness 

1  broke 

1  enemies 

1  lawyer 

1  release 

8  unhappy 

1  burden 

1  enemy 

1  lessons 

1  relief 

1  unlucky 

1  burdens 

1  error 

2  life 

1  remorse 

2  unnecessary 

I  business 

1  everywhere 

1  little 

1  rest 

5  unpleasant 

1  busy 

1  exams 

1  lonesonJe 

2  reverses 

3  unpleasantness 

1  excited 

1  loss 

1  Romeo 

1  unrest 

1  calm 

2  excitement 

5  lots 

1  ruffled 

1  unsafe 

1  calmness 

2  unsatisfactory 

27  care 

3  family 

2  mad 

6  sad 

1  unsettled 

3  cares 

1  father 

1  madness 

13  Sadness 

2  upset 

1  careless 

3  fear 

5  man 

1  school 

4  children 

1  feeling 

1  many 

1  scrape 

1  want 

1  college 

1  few 

2  marriage 

1  sea 

2  war 

6  comfort 

5  fight 

2  me 

1  seldom 

1  weak 

1  comforts 

2  fighting 

10  mind 

1  sereneness 

3  weary 

1  comfortable 

1  flunking 

1  minded 

1  shadow 

2  weeping 

2  coming 

1  fret 

3  mischief 

1  ship 

1  welfare 

1  consequences 

1  friends 

1  miserable 

1  shooting 

1  woe 

2  contented 

1  fun 

14  misery 

47  sickness 

5  woman 

1  contentment 

1  funeral 

6  misfortune 

1  simple 

1  women 

1  court 

3  fuss 

1  misunder- 

1 sin 

8  work 

1  cry 

standing 

1  sleep 

1  worked 

1  crying 

2  girl 

4  money 

1  sometimes 

1  working 

2  gossip 

1  monotony 

202  sorrow 

3  worried 

6  danger 

2  great 

1  mother 

1  sorrows 

2  worries 

1  darkness 

26  grief 

1  Mrs.   Wiggs 

4  sorrowful 

65  worry 

1  day 

5  much 

1  sport 

1  worrying 

16  death 

1  handkerchief 

1  squabble 

5  worriment 

2  deep 

19  happiness 

1  nervousness 

1  study 

2  wrinkles 

2  despair 

8  happy 

3  no 

1  suffer 

2  wrong 

1  difficult 

5  hard 

2  noise 

1  suffering 

1  difficulties 

6  hardship 

4  none 

1  sweetener 

1  yesterday 

1  difficulty 

1  harm 

1  nuisance 

2  sympathy 

1  youth 

46.    SOLDIKR 


1  academy 

1  bravcness 

1  colonel 

1  drums 

1  fortune 

1  armies 

8  bravery 

6  command 

4  duty 

137  army 

1  Brazilian 

1  commanding 

4  general 

3  arms 

1  brother 

3  commander 

1  enemy 

1  Germany 

1  Arnold 

2  buttons 

1  costume 

1  England 

1  glory 

2  artillery 

4  country 

1  English 

3  good 

4  cadet 

5  courage 

3  erect 

1  Grant 

1  baseball 

2  camp 

8  guard 

8  battle 

2  cannon 

1  danger 

1  fellow 

1  guardian 

1  bayonet 

1  cap 

2  defender 

17  fight 

1  guardsman. 

1  blood 

8  captain 

1  defense 

1  fights 

27  gun 

1  blue 

3  cavalry 

2  discipline 

12  fighter 

2  guns 

23  boy 

14  citizen 

1  disliked 

12  fighting 

1  boys 

3  civilian 

1  double 

1  firearm 

1  Tielmet 

40  brave 

1  clothes 

2  drill 

2  fort 

8  hero 

FREQUENCY  TABLES 


577 


1  him 

2  marshal 

5  patriot 

1  salute 

1  training 

1  hobo 

2  mechanic 

1  patriotic 

1  sentry 

1  travel 

1  home 

17  military 

1  patriotism 

1  servant 

1  troop 

1  hurt 

3  militia 

3  person 

1  service 

1  troops 

1  murder 

1  Philippines 

1  show 

2  infantry 

1  music 

1  police 

1  sick 

39  uniform 

2  musket 

6  policeman 

1  single 

1  United  Statffl 

1  jacky 

1  protection 

1  smart 

3  upright 

1  Jim 

1  N. 

2  protector 

1  sorrow 

1  uprightness 

1  nation 

1  proud 

1  stateliness 

1  king 

1  national 

1  store 

1  valiant 

2  navy 

4  red 

3  straight 

3  veteran 

5  lieutenant 

1  necessary 

1  redcoat 

1  strength 

3  volunteer 

1  nobility 

1  regiment 

1  strenuous 

3  male 

2  regular 

-1  strict 

94  war 

189  man 

1  obedience 

1  respectable 

4  strong 

1  warfare 

4  men 

1  obey 

1  Richmond 

2  sword 

12  warrior 

1  manly 

12  officer 

3  rifle 

3  West  Point 

12  march 

1  officers 

2  tall 

2  widow 

5  marching 

1  order 

58  sailor 

1  tent 

2  work 

1  marine 

2  orderly 

1  sailors 

4  tin 

47.     CABBAGE 


1  away 

30  eat 

30  head 

3  onions 

2  soup 

6  eating 

1  heads 

4  sour 

1  bad 

6  eatable 

1  healthy 

1  paper 

1  spice 

2  beans 

3  eatables 

2  heavy 

1  parsley 

1  spinach 

11  beef 

1  herb 

16  patch 

1  sprouts 

1  beet 

11  farm 

1  home 

48  plant 

3  stalk 

2  beets 

1  farming 

2  hcrrid 

3  plants 

1  stew 

1  boiled 

3  field 

1  plantation 

1  stinking 

1  broth 

2  fields 

S  indigestion 

1  planted 

1  strong 

1  bud 

1  fine 

1  planting 

1  sustenance 

1  bunchy 

4  flower 

1  kale 

1  plate 

3  sweet 

22  food 

2  kraut 

5  pork 

2  carrot 

7  fruit 

5  potato 

3  taste 

1  carrots 

8  large 

18  potatoes 

1  tender 

1  catsup 

43  garden 

9  leaf 

1  purple 

2  tomato 

17  cauliflower 

1  German 

11  leaves 

2  tomatoes 

1  cigar 

1  Germans 

11  letters 

1  quart 

20  turnip 

1  cold-slaw 

1  goat 

1  lot 

6  turnips 

1  cook 

13  good 

2  rabbit 

4  cooking 

44  green 

2  meal 

3  red 

1  unnecessary 

1  com 

3  greens 

8  meat 

2  rose 

1  unwholesome 

1  cucumbers 

3  ground 

2  Mrs.    Wiggs 

4  round 

1  cut 

1  grow 

1  mustard 

1  Valhalla 

1  grows 

5  salad 

394  vegetable 

1  decayed 

2  growing 

1  nice 

17  sauerkraut 

10  vegetables 

1  disagreeable 

1  growth 

1  nothing 

2  slaw 

4  vinegar 

2  dish 

11  smell 

1  Virginia 

1  dislike 

1  ham 

2  odor 

1  soapy 

4  dinner 

3  hard 

2  onion 
48.   HARD 

2  solid 

1  white 

2  adamant 

2  cabbage 

1  earth 

2  glass 

1  indestructible 

8  apple 

1  callous 

1  earthen 

1  glittering 

1  individual 

1  apples 

2  candy 

17  easy 

1  gold 

1  indurated 

1  can't 

2  egg 

2  good 

1  inflexible 

2  bad 

3  chair 

1  <iSS^ 

1  granite 

1  injustice 

5  ball 

1  character 

1  examination 

2  ground 

1  irksome 

1  baseball 

7  coal 

44  iron 

1  bed 

1  coarse 

1  face 

1  hammer 

1  bench 

1  cold 

1  farmer 

2  harsh 

1  kind 

1  blackboard 

1  crystallized 

1  feary 

2  heart 

6  board 

4  feeling 

2  hearted 

1  labor 

2  boards 

1  dense 

11  firm 

2  heavy 

2  lead 

1  bone 

3  diamond 

2  firmness 

1  hickory 

2  lesson 

1  bread 

5  difficult 

1  fist 

1  hurt 

1  lignum- vltae 

1  break 

1  disagreeable 

4  flint 

2  life 

12  brick 

1  do 

16  floor 

8  ice 

1  low 

2  brittle 

1  durabiUty 

1  formidable 

1  immovable 

3  luck 

2  bullet 

1  fruit 

1  impenetraole 

578 


FREE  ASSOCIATION  TEST 


1  maple 

2  pavement 

1  rocky 

1  strength 

1  uneasy 

8  marble 

1  perplexing 

11  rough 

4  strong- 

1  unimpression- 

I mathematics 

1  physics 

1  stuff 

able 

2  mean 

1  piino 

1  saltpetre 

6  substance 

2  unpleasant 

2  medium 

1  principle 

1  severe 

1  unpliable 

5  metal 

1  pulpy 

1  sidewalk 

5  table 

1  unripe 

1  murder 

15  smooth 

1  tack 

I  unyielding 

1  mush 

1  quality 

367  soft 

1  thick 

1  uselessness 

1  questions 

15  solid 

1  tight 

1  nail 

1  stale 

2  touch 

I  very 

1  nails 

1  raining 

14  steel 

12  tough 

1  natural 

4  resistance 

1  stick 

2  tree 

1  walnuts 

1  nut 

1  resistant 

1  stingy 

1  trouble 

2  water 

1  nuts 

1  rigid 

102  stone 

1  turnip 

1  wisdom 

1  road 

1  stones 

66  wood 

1  oak 

38  rock 

1  stony 

5  unbreakable 

19  work 

1  opaque 

4  rocks 

2  stove 
40.  BAGLS: 

6  uncomfortable 

2  worMEg 

3  air 

1  cruelty 

1  graceful 

8  paper 

1  spread 

1  altitude 

1  gray 

1  parrot 

11  strength 

7  America 

4  dollar 

1  great 

1  partridge 

3  strong 

12  American 

5  dove 

1  peacock 

1  sun 

4  animal 

13  hawk 

2  pigeon 

3  swallow 

1  aspiring 

1  eggs 

1  height 

2  power 

1  swan 

8  emblem 

21  high 

5  prey 

4  swift 

1  bald 

12  eye 

1  swiftness 

8  beak 

1  eyed 

1  insect 

1  quail 

1  sword 

2  beast 

1  eyry 

1  insignium 

1  quarry 

2  bill 
668  bird 

1  falcon 
7  feathers 

1  keen 

1  robin 

1  talon 
1  talons 

6  birds 

1  fierce 

4  king 

1  rock 

1  tern 

1  birdie 

2  flag 
6  flies 

•  1  Times 

1  black 

9  large 

1  scarce 

1  turkey 

1  butterfly 

2  buzzard 

22  flight 
1  flint 

Hark 
1  liberty 

3  sharp 
1  sight 

2  United  States 

1  carnivorous 

46  fly 
23  flying 

2  lofty 

2  sky 
2  sly 

8  vulture 

1  carrion 

2  flyer 

3  fowl 

2  might 

6  soar 

1  chickens 

14  mountain 

3  soars 

8  wing 

2  claws 

S  freedom 

8  mountains 

14  soaring 

16  wings 

1  clouds 

1  solitude 

1  contour 

1  glare 

12  nest 

1  space 

1  young 

1  crag 

1  glorious 

6  sparrow 

3  crow 

2  golden 

4  owl 

1  sport 

2  Zoo 

60.    STOMACH 


82  abdomen 

8  cancer 

1  dress 

5  gastric 

2  internal 

SI  ache 

1  care 

1  duodenum 

1  Gertrude 

28  intestine 

21  anatomy 

2  careful 

4  dyspepsia 

4  good 

32  intestines 

2  animal 

1  cat 

1  grind 

5  appetite 

1  cavity 

45  eat 

2  grinding 

1  juice 

1  apples 

1  chart 

27  eating 

2  arm 

18  chest 

8  empty 

2  hand 

4  large 

1  coil 

1  engine 

1  hands 

lleg 

1  back 

2  condition 

1  excellent 

9  head 

1  limb 

1  bad 

1  contain 

5  health 

13  liver 

7  bag 

1  face 

24  heart 

1  living 

1  basket 

1  delicate 

1  fat 

1  hog 

1  lung 

2  beast 

1  diaphragm 

1  feed 

6  hunger 

3  lungs 

1  beef 

6  digest 

1  feeding 

6  hungry 

6  belly 

1  digesting 

1  feet 

2  hurt 

1  machinery 

1  belt 

50  digestion 

102  food 

1  hurts 

5  man 

1  biology 

3  digestive 

2  foot 

1  hygiene 

1  meal 

99  body 

2  digests 

1  flesh 

1  meals 

13  bowels 

7  dinner 

1  frame 

1  illness 

6  member 

1  train 

1  disease 

1  front 

17  indigestion 

1  milk 

1  bread 

1  distress 

7  full 

5  inside 

1  mortal 

1  breast 

8  doctor 

1  function 

2  interior 

3  mouth 
I  muscle 

FREQUENCY  TABLES 


579 


S  nausea 

28  pain 

3  receptacle 

1  specimen 

S  troublesoma 

3  necessary 

3  part 

2  reservoir 

1  strong 

1  trunk 

1  necessity 

9  person 

1  rest 

1  suffer 

3  tube 

1  neck 

3  physiology 

3  round 

1  suffering 

1  nuisance 

1  picture 

1  sustenance 

1  upset 

2  poor 

1  self 

2  system 

1  useful 

1  object 

1  portion 

10  sick 

1  oblong 

4  pouch 

7  sickness 

1  tender 

2  vessel 

4  oesophagus 

1  psychology 

1  skin 

1  tenderness 

81  organ 

3  pump 

2  small 

1  thought 

1  want 

3  organs 

2  punch 

4  soft 

1  throat 

1  water 

1  overeating 

1  sore 

2  tongue 

3  weak 

1  overloaded 

1  receiver 

2  sour 

51.    STEM 

25  trouble 
1  troubles 

1  weakness 
1  work 

1  anything 

1  ending 

lleg 

3  piece 

1  stiff 

1  appendage 

1  evolution 

3  length 

70  pipe 

1  stone 

43  apple 

1  lettuce 

1  pit 

1  stop 

1  apples 

1  fibre 

1  life 

74  plant 

1  storm 

2  fibres 

2  lisht 

1  plow 

2  straight 

1  base 

1  finger 

1  lily 

6  point 

8  support 

3  beginning 

259  flower 

4  limb 

1  poppy 

1  blade 

7  flowers 

1  living 

1  projection 

4  thin 

3  blossom 

2  foundation 

18  long 

1  prop 

2  thom 

1  boat 

14  fruit 

2  tide 

1  body 

1  match 

1  reed 

1  tobacco 

1  brain 

1  grass 

1  river 

1  top 

83  branch 

9  green 

1  necessity 

1  rod 

44  tree 

1  branches 

3  growth 

27  root 

2  trees 

1  broad 

1  object 

1  roots 

3  trunk 

1  broom 

20  handle 

1  offshoot 

21  rose 

7  twig 

4  bud 

1  hard 

1  organ 

5  bush 

Ihead 

2  shank 

1  valve 

1  butt 

2  hold 

4  part 

6  short 

1  violet 

1  holding 

1  parts 

7  slender 

3  vine 

2  cane 

4  holder 

1  particle 

1  small 

2  cherry 

1  holes 

2  peach 

1  smoke 

7  watch 

3  connection 

9  pear 

1  soft 

2  water 

1  connects 

1  join 

1  peduncle 

21  stalk 

3  weed 

2  cord 

3  pencil 

2  steps 

3  wind 

2  core 

96  leaf 

4  petal 

6  stem 

2  winding 

4  leaves 

1  pick 

14  stick 

3  winder 

10  end 

52.  liAHfP 

4  wood 

1  Aladdin 

1  crockery 

8  glass 

1  match 

1  shadow 

1  arc 

7  globe 

1  small 

6  articles 

1  dangers 

1  nickle 

4  smoke 

3  dark 

3  high 

4  night 

1  smokes 

6  black 

2  darkness 

1  home 

1  smoking 

1  blaze 

1  daylight 

1  hot 

49  oil 

1  smoky 

1  brass 

1  distance 

1  house 

1  ornament 

2  stand 

12  bright 

Idull 

1  stove 

3  brightness 

2  illumination 

1  petroleum 

1  student 

20  bum 

5  electric 

5  post 

10  burning 

1  evening 

7  kerosene 

1  pretty 

8  table 

3  burner 

1  taU 

1  bums 

5  fire 

1  lantern 

2  reading 

1  flame 

2  larg-.e 

1  red 

2  useful 

13  candle 

1  full 

1  library 

1  Rochester 

2  chandelier 

2  furniture 

650  light 

2  room 

2  vessel 

1  cheer 

2  lights 

87  chimney 

4  gas 

4  lighted 

2  see 

1  warmth 

2  convenience 

1  glaring 

1  lighten 

2  lit 

37  shade 

23  wick 
1  wisdom 

580 


FREE  ASSOCIATION  TEST 


53.    DREiAM 

1  absence 

1  eyes 

2  lie 

1  psychology 

1  stale 

1  angel 

1  like 

1  purple 

1  startling 

1  angels 

2  falling 

2  love 

1  story 

1  anger 

9  fancy 

1  queer 

14  sweet 

1  anything 

1  fantasy 

1  M. 

1  quiet 

6  asleep 

1  fear 

2  man 

1  talk 

11  awake 

1  feeling 

1  mare 

1  realization 

1  terrible 

1  awaking 

1  feelings 

1  meditate 

1  recollection 

8  things 

1  awaken 

1  forgotten 

1  melancholy 

1  relax 

29  think 

3  awakening 

1  fortune 

1  melody 

1  remember 

8  thinking 

1  funny 

1  mesmeric 

2  repose 

38  thought 

2  baby 

8  mind 

1  reposing 

22  thoughts 

16  bad 

1  girl 

1  money 

3  rest 

1  tiring 

4  beautiful 

7  good 

1  music 

6  restless 

1  trouble 

11  bed 

1  goodness 

1  restlessness 

2  true 

3  bliss 

1  grand 

2  nature 

2  reverie 

1  book 

1  grieving 

1  never 

1  uncomfortable 

1  boy 

3  nice 

2  sad 

1  unconscious 

2  hallucination 

42  night 

1  sadness 

1  unconsciousness 

1  comfort 

3  happiness 

24  nightmare 

1  scene 

1  uneasiness 

2  consciousness 

1  heaven 

1  no 

1  second 

2  uneasy 

1  conversation 

3  home 

1  none 

1  semiconscious 

1  unfortunate 

1  hope 

2  nonsense 

1  sensation 

5  unpleasant 

1  dangerous 

3  horrible 

1  sense 

1  unpleasantness 

1  darkness 

1  object 

1  shade 

2  unreal 

1  days 

1  idea 

1  omen 

1  shadows 

2  unrest 

2  death 

3  illusion 

1  on 

1  short 

1  unstable 

1  delusion 

1  image 

1  opium 

2  sickness 

1  delusions 

2  imaginary 

1  sight 

1  Vacancy 

1  disagreeable 

12  imagination 

1  paradise 

1  sights 

1  vaguenera 

1  disappointment 

5  imagine 

1  patients 

330  sleep 

48  vision 

1  discontent 

1  imaginings 

1  peace 

39  sleeping 

6  visions 

2  disturbance 

2  impression 

2  peaceful 

2  sleeper 

1  vivid 

1  disturbing 

2  indigestion 

1  phantoms 

2  sleeplessness 

1  doze 

1  insanity 

3  picture 

2  sleepy 

9  wake 

1  dread 

1  inspiration 

1  pillow 

1  slept 

1  waking 

2  dreary 

1  play 

20  slumber 

1  wander 

1  kind 

38  pleasant 

1  something 

4  wandering 

1  e-asy 

13  pleasure 

1  somnambulist 

1  weird 

1  expectation 

1  land 

1  presentiment 

2  snore 

2  wonder 

1  experiment 

2  languid 

1  prophesy 
64.   YELL.OTV" 

1  soliloquy 

1  woods 
1  work 

1  alive 

1  coarse 

9  flowers 

2  lily 

34  red 

2  amber 

301  color 

3  fruit 

1  ribbon 

3  apple 

1  coloring 

1  maize 

9  rose 

1  autumn 

1  common 

1  O. 

1  man 

1  complexity 

1  garments 

1  marigolds 

1  satin 

5  banana 

1  corn 

1  gay 

1  matter 

1  school 

3  beautiful 

2  cream 

1  glare 

1  mellow 

1  sear 

2  beauty 

1  crocus 

13  gold 

1-  melon 

4  shade 

1  becoming 

5  golden 

1  molasses 

1  silk 

8  bird 

3  daffodil 

1  goldenglow 

2  sky 

24  black 

3  daffodils 

5  goldenrod 

1  nature 

2  soft 

1  blossoms 

6  daisy 

1  goods 

1  nice 

1  spectrum 

41  blue 

7  dandelion 

1  gorgeous 

1  suit 

23  bright 

6  dark 

1  grass 

1  obnoxious 

1  sulphur 

2  briRhtness 

1  delightful 

41  green 

1  ochre 

21  sun 

1  brilliant 

1  desert 

47  orange 

8  sunflower 

13  brown 

1  disagreeable 

2  hair 

7  sunlight 

1  buff 

1  dog 

2  house 

5  paint 

1  sunshine 

7  butter 

1  door 

1  hue 

2  pale 

11  buttercup 

1  dream 

3  pansy 

1  table 

2  buttercups 

9  dress 

1  ink 

4  paper 

2  tan 

8  butterfly 

1  dresses 

2  peach 

1  tarnish 

1  dull 

2  jasmine 

1  pears 

1  tree 

4  canary 

3  jaundice 

1  pillow 

1  ugly 

1  cat 

1  ecru 

6  jealousy 

13  pink 

2  China 

1  egg 

1  jonquil 

1  plague 

1  unharmonious 

8  Chinaman 

2  journal 

1  poppy 

2  violet 

3  Chinee 

1  fade 

4  pretty 

2  Chinese 

1  fancy 

2  kid 

1  primrose 

1  wagon 

1  chrome 

1  fence 

2  pumpkin 

1  warm 

1  chrysanthemum    3  fever 

2  leaf 

1  pumpkins 

1  warmth 

1  chrysanthe- 

4 flag 

1  leaves 

1  pure 

1  wax 

mums 

1  flame 

7  lemon 

5  purple 

1  wheat 

3  cloth 

38  flower 

11  light 

70  white 

FREQUENCY  TABLES 


581 


B6.  BRK 

1  appetite 

6  cnirt 

2  grain 

1  milk 

1  sour 

1  cut 

1  mixing 

8  staff 

2  bake 

1  ham 

3  stale 

4  bakiiig 

3  daily 

1  hand 

1  necessary 

1  strengthen 

3  baker 

4  diet 

3  hard 

2  necessity 

2  substance 

1  bakery 

6  dinner 

2  heavy 

1  needful 

1  sub3tanti«l 

14  biscuit 

1  dish 

1  holes 

4  nourishment 

1  sugar 

2  biscuits 

26  dough 

2  home 

1  sustenance 

4  blue 

1  doughnuts 

1  hot 

1  oatmeal 

4  sweet 

1  board 

7  hunger 

1  box 

1  earn 

4  hungry 

1  pantry 

3  table 

2  breakfast 

148  eat 

1  pastry 

2  tea 

3  brown 

44  eating 

8  knife 

1  plate 

1  toast 

1  buns 

28  eatable 

1  pudding 

1  tough 

151  butter 

6  eatables 

23  life 

1  edible 

8  light 

1  roll 

1  useful 

15  cake 

1  living 

2  rolls 

1  cheese 

1  feed 

7  loaf 

6  rye 

9  water 

1  children 

88  flour 

1  lunch 

21  wheat 

1  color 

191  food 

1  salt 

15  white 

1  common 

3  fresh 

1  making 

1  salty 

1  wholesome 

1  cookies 

2  fruit 

2  man 

1  satisfaction 

1  wine 

1  com 

1  meal 

1  sister 

1  winner 

1  crackers 

21  good 

5  meat 

8  soft 

1  crumbs 

2  graham 

66.   justice: 

8  yeast 

2  action 

3  do 

1  have 

1  merit 

4  satisfaction 

2  administered 

2  doing 

1  heaven 

1  mind 

1  satisfied 

1  administration 

1  done 

1  help 

1  moral 

1  satisfying 

2  all 

1  Dr.    E. 

1  him 

1  mother 

5  scales 

1  always 

5  duty 

5  honest 

2  severe 

1  ask 

3  honesty 

1  never 

1  severity 

1  authority 

1  elusive 

7  honor 

1  nobility 

1  sorrow 

1  emblem 

1  noble 

3  square 

1  B. 

1  employer 

1  impartial 

1  none 

1  squareness 

1  bad 

1  energy 

1  iniquity 

1  nonsense 

1  squire 

1  bed 

3  equal 

1  injury 

4  statue 

3  blind 

9  equality 

26  injustice 

1  obey 

1  story 

1  blindfolded 

1  equally 

1  innocent 

1  obtain 

3  supreme 

1  body 

3  equity 

1  oppression 

2  sure 

2  even 

1  J. 

4  order 

1  caug-ht 

1  exactness 

2  jail 

1  tranquility 

1  charity 

1  execution 

1  joy 

1  pardon 

6  true 

1  chastise 

1  judge 

4  partiality 

14  truth 

1  chief 

32  fair 

1  judged 

143  peace 

2  truthfiilnees 

1  clearness 

21  fairness 

6  judgmff 

1  perfect 

1  comfort 

1  favor 

3  jury 

1  person 

1  unbias 

3  command 

1  fear 

5  just 

1  picture 

1  unfaimesE 

1  commanding 

1  fine 

4  justified 

1  Plato 

1  unhappineas 

1  conqueror 

6  freedom 

1  police 

3  unjust 

1  constable 

1  friendship 

6  kindness 

1  policeman 

1  uprightness 

64  court 

1  politics 

2  courts 

1  gift 

1  lacking 

1  popular 

1  vengeance 

1  Creator 

1  give 

1  large 

1  power 

S  virtue 

1  crime 

3  given 

74  law 

1  privilege 

1  criminal 

3  God 

2  lawful 

1  purity 

2  well 

2  cruelty 

1  godliness 

4  lawyer 

1  wicked 

14  good 

2  lenient 

1  reason 

1  willingness 

1  dealing 

2  goodness 

11  liberty 

2  reward 

2  wisdom 

1  deeds 

1  govern 

1  lots 

57  right 

1  wise 

1  defying 

3  government 

1  love 

3  righteous 

2  work 

1  delayed 

1  guilty 

13  righteousness 

8  wrong 

1  demand 

2  magistrate 

1  rightly 

1  deserved 

1  happy 

13  man 

1  rightness 

1  yes 

2  dispute 

1  harm 

1  merciful 

11  rights 

1  yield 

1  distribution 

1  hastr 

28  mercy 

1  ruler 

582 


FREE  ASSOCIATION  TEST 


57.  BOY 

2  action 

1  dog 

1  incorrigible 

1  mother 

S  eon 

2  active 

1  industrious 

1  muscles 

1  spirit 

2  acti\'ity 

1  Edward 

2  infant 

1  myseU 

1  spoiled 

1  agility 

1  eighteen 

1  inhabitant 

2  sport 

S  animal 

1  embryonic 

1  innocent 

1  naughty 

1  street 

3  athletic 

1  errand 

2  Ned 

S  strength 

2  athleti' 

1  jacket 

1  nephew 

3  strong 

1  fair 

2  James 

1  newspaper 

2  suit 

6  baby 

3  female 

1  Jimmy 

3  nice 

1  sweetheart 

9  bad 

1  fight 

1  Joe 

7  noise 

1  swimming 

10  ball 

1  flesh 

1  joyful 

3  noisy 

1  barefoot 

1  foolish 

1  jump 

1  nuisance 

3  taU 

5  baseball 

1  football 

1  jumper 

1  terror 

1  beautiful 

1  Frank 

2  juvenile 

1  obedient 

1  think 

6  being 

4  friend 

1  out 

1  Thomas 

1  Ben 

2  frolic 

4  kid 

2  top 

2  body 

4  fun 

6  pants 

1  toys 

1  boisteroi 

1  funny 

7  lad 

1  Paul 

1  Tracy 

1  book 

2  large 

11  person 

1  trait 

2  bright 

1  games 

1  laugh 

20  play 

1  tramp 

6  brother 

819  girl 

1  legs 

1  plays 

1  trouble 

2  busy 

7  good 

2  life 

1  plaj-ful 

1  grown 

3  little 

1  playfulness 

1  useless 

1  cap 

1  growth 

3  lively 

2  pupil 

1  careless 

2  gun 

1  walk 

1  Charles 

1  maid 

6  rough 

1  water 

1  chicken 

1  handsome 

63  male 

1  running 

1  whistle 

86  child 

1  Harry 

104  man 

1  runs 

1  whistles 

1  children 

1  hat 

1  manhood 

1  wicked 

1  class 

1  head 

1  mankind 

1  scallywag 

2  wild 

1  clothes 

1  hearty 

1  manliness 

2  scamp 

1  wildness 

1  clothing 

1  hero 

1  manly 

1  scholar 

2  woman 

2  companion 

2  hood 

1  marbles 

11  school 

1  woods 

1  cousin 

2  hoop 

3  masculine 

4  sex 

1  work 

1  curls 

9  human 

2  master 

1  sharp 

1  working 

1  humanity 

1  meanness 

2  shoes 

1  dead 

1  Michael 

14  small 

22  young 

1  development 

1  imbecile 

11  mischief 

2  smart 

1  youngster 

2  dirty 

1  imperfect 

7  mischievous 
68.  LIGHT 

1  nmiles 

33  youth 
1  youthful 

1  agreeable 

231  dark 

1  glare 

7  morning 

1  sign 

8  air 

93  darkness 

1  gleam 

8  sky 

1  airy 

2  dawn 

3  good 

1  nice 

1  soft 

1  arc 

81  day 

3  night 

1  sound 

1  assistance 

2  daylight 

2  hair 

1  necessity 

1  space 

1  awake 

6  daytime 

4  happiness 

1  splendor 

1  dimness 

1  health 

1  paper 

1  steam 

1  beacon 

1  distance 

1  healthy 

1  pathway 

85  Sim 

2  beautiful 

1  dress 

1  hearted 

1  peaceful 

1  sunlight 

1  beautifying 

1  dull 

8  heat 

1  pink 

11  sunshine 

1  beauty 

1  heaven 

1  pipe 

1  swift 

1  biscuit 

2  early 

5  heavy 

1  placid 

3  black 

1  easy 

1  hills 

3  pleasant 

1  transparent 

2  blue 

1  education 

1  pleasure 

1  truth 

1  bread 

7  electric 

1  illuminate 

1  plenty 

1  twilight 

47  bright 

8  electricity 

7  illuminat' 

21  brightness 

1  element 

2  rays 

1  ventilation 

3  brilliant 

1  emptiness 

1  joy 

1  red 

1  Vera 

1  brown 

1  enjoy 

1  reflection 

1  vibration 

2  bum 

1  evening 

1  kerosene 

1  right 

2  vision 

1  burning 

1  eyes 

1  knowledge 

3  room 

1  vivid 
1  waist 

8  candle 

1  fair 

1  laboratory 

24  see 

2  warmtll 

1  cheer 

6  feather 

82  lamp 

3  seeing 

1  waves 

2  clear 

1  feathers 

1  lamps 

1  seen 

1  weak 

2  cleamf 

6  fire 

7  life 

8  shade 

2  weight 
8  white 

2  coat 

1  flame 

1  long 

2  shadow 

19  color 

1  fleshy 

1  look 

1  shadows 

2  whiteness 

2  comfort 

1  forward 

1  luminous 

2  shine 

25  window 

1  complexion 

1  fuel 

2  shines 

1  world 

1  convenient 

1  match 

2  shining 

1  cork 

21  eras 

10  moon 

3  sieht 

6  yellow 

FREQUENCY  TABLES 


583 


69.  HEALTH 


1  action 

3  desirable 

111  happiness 

1  optimism 

5  sound 

2  activity 

9  disease 

7  happy 

1  spirit 

9  air 

4  doctor 

1  haste 

1  pain 

1  spirits 

1  athletics 

1  healing 

8  perfect 

1  state 

1  eating 

1  healthful 

6  person 

112  strength 

5  bad 

5  enjoyment 

1  healthy 

3  physical 

1  strengths 

1  baseball 

2  everything 

1  heaven 

1  physician 

31  strong 

1  beautiful 

1  excellent 

2  holiness 

1  physiology 

1  sturdy 

10  beaut}' 

1  excursion 

2  hygiene 

1  play 

1  success 

1  better 

3  exercise 

2  pleasant 

4  blessing 

1  existence 

3  ill 

14  pleasure 

1  temper 

1  blood 

13  illness 

1  plenty 

2  thankful 

1  board 

1  face 

2  poor 

1  trouble 

9  body 

2  feel 

6  joy 

1  preserve 

1  boon 

12  feeling 

1  proper 

1  unhealthiness 

2  boy 

1  fine 

5  life 

4  prosper" 

3  unhealthy 

1  broad 

4  food 

1  light 

2, useful 

2  buoyancy 

1  form 

1  live 

1  quick 

/ 

2  fortune 

3  living 

1  valuable 

1  care 

1  freedom 

2  luck 

1  red 

11  vigor 

1  careful 

1  fun 

1  luxury 

3  riches 

1  virility 

1  cheer 

9  robust 

1  circulation 

3  gift 

4  man 

1  rose 

1  walking 

1  cleanliness 

1  girl 

1  me 

3  rosy 

2  want 

X  climate 

2  gladness 

3  medicine 

1  round 

1  warm 

1  color 

1  glow 

1  merriment 

2  rugged 

1  water 

26  comfort 

1  golf 

1  mother 

1  weakness 

6  condition 

94  good 

1  mountain 

1  self 

76  wealth 

1  constitution 

1  goodness 

1  moving 

9  sick 

63  well 

1  consumption 

2  grand 

2  sickly 

1  wholesome 

1  contentment 

1  gymnasium 

1  necessary 

153  sickness 

1  woman 

1  convenience 

1  gymnastics 

1  needed 

1  smiles 

1  wonderful 

2  country 

1  needful 
4  normal 

60.  BIBLE3 

1  youth 

1  academy 

1  encyclopedia 

1  Jacob 

1  paper 

1  sour 

1  all 

1  excellent 

4  Jesus 

1  piety 

1  stones 

1  ancient 

2  knowledge 

2  pious 

2  stories 

1  fable 

1  Koran 

3  pray 

4  story 

1  beauty 

1  faith 

Z  praying 

1  strength 

1  belief 

2  family 

4  large 

19  prayer 

2  studies 

1  beneficial 

3  law 

7  prayers 

6  study 

2  black 

1  Genesis 

1  leaf 

13  prayer-book 

6  Sunday 

S3S  book 

1  glass 

1  leaves 

2  preacher 

1  books 

43  God 

1  lectern 

1  preaching 

3  table 

28  good 

1  legend 

1  prophet 

1  teach 

1  catechism 

12  goodness 

2  lie 

4  psalms 

1  teacher 

8  Christ 

3  gospel 

3  life 

1  teachings 

3  Christian 

1  gospels 

2  li?ht 

1  rarely 

24  Testament 

50  church 

1  grand 

2  literature 

31  read 

4  text 

3  class 

1  guide 

5  Lord 

19  reading 

1  tradition 

1  clean 

2  love 

1  reformation 

2  true 

1  clergyntan 

2  heaven 

89  religion 

17  truth 

2  comfort 

1  heavy 

1  message 

4  religious 

1  truthfulness 

2  command 

1  help 

1  mine 

1  reverence 

1  commandment 

26  history 

3  minister 

1  righteous 

1  unnecessary 

2  commandments 

5  holiness 

2  Moses 

3  rot 

2  useful 

1  creed 

57  holy 

1  mother 

2  home 

3  sacred 

1  verses 

1  devotion 

1  hope 

1  necessary 

2  Saviour 

1  directions 

2  hymns 

1  noble 

2  school 

1  weariness 

1  drama 

17  scripture 

8  word 

2  duty 

1  instructive 

2  obey 

3  scriptures 

1  words 

1  open 

1  sermon 
1  Shelf 

2  worship 
1  writ 

584 


FREE  ASSOCIATION  TEST 


2  absent 
1  acquire 
1  aid 
1  aiialysis 

1  ancient 

2  association 
1  attention 
1  attitude 

1  aunt 

1  back 
19  bad 
1  beautiful 

1  bird 

3  blank 

2  book 

3  books 
16  brain 

5  brains 
1  brightness 
!■ bucket 

1  catechism 
1  cause 
1  charming 

4  childhood 

1  clear 

2  concentration 
1  connection 

1  conscience 

2  consciousness 

1  dancing 
1  death 

1  debts 

2  defect 

1  defective 
1  desirable 
1  deterioration 
1  dictionary 
1  dim 
1  distant 
1  dream 

3  dreams 
1  dull 

1  easy 
1  educated 
1  effort 
1  elusive 


225  animal 
13  animals 
1  astray 
1  awkward 

1  baa 

3  beast 

1  bed 

1  Bethlehem 

6  black 

1  blind 

1  buffalo 

1  calf 

1  cilm 
47  cattle 

1  cloth 

8  country 
22  cow 

6  COWB 

1  death 

2  deer 
2  dirty 
6  dog 
2  dogs 


1  English 

1  Europe 

2  events 

1  everything 

2  excelleni 

1  experiment 

1  faces 
1  faculty 
1  failing 
1  fails 

4  fair 

1  fancy 
1  far 
1  farther 
1  fascination 
1  faulty 
1  feeling 
1  fine 
1  fleeting 
1  fond 
1  fool 
25  forget 

5  forgetful 

37  forgetfulness 

6  forgetting 

3  forgotten 
1  forty 

1  friends 

2  gone 
68  good 

1  gravestone 

1  great 

2  green 

1  happines 
1  happy 
9  head 

1  hearing 

2  history 
2  home 

1  hopefulness 

2  idea 

1  image 

2  imagination 
1  impossible 

1  increase 
7  intellect 


1  eat 

4  farm 

1  feed 
12  field 

6  fields 

8  fleece 

1  flesh 
24  flock 

1  flocks 

4  fold 

1  follow 

2  food 

1  foolish 
1  fowl 
1  fur 

1  gentle 
1  gentleness 

1  goad 
17  goat 
10  goats 

2  good 
4  grass 
1  graze 

^  grazing 


61.   MEMORY 

5  intelligence 
1  interpret 
1  invisible 


1  joy 

1  keep 

1  know 

4  knowledge 

2  lack 

2  lacking 
1  language 
1  lasting 

1  learn 

2  learning 
1  lecture 

1  length 

2  lessons 
1  light 

3  long 
1  loss 
1  love 

magnificent 

3  man 

1  marvelous 
1  me 

1  memorandum 
1  memorizing 

4  mental 
138  mind 

1  mindful 

2  mnemonics 
1  mother 

1  mud 
1  my 
1  myself 

1  names 

3  necessary 
1  necessity 
1  needful 

1  noble 
1  none 

1  oblivion 

1  painful 
8  past 

62.   SHE^EIP 

1  group 

1  hair 

1  harmless 

4  herd 

1  herder 

1  hill 

2  hillside 
1  horn 

1  horse 

1  humanity 

6  innocence 

2  innocent 

1  Jump 

151  lamb 
36  lamba 

1  landscape 

2  large 

1  lecture 
1  lowing 

1  many 

3  meadows 


1  patient 

1  pen 

2  perception 
2  person 

2  picture 
1  pictures 

1  pleasantness 

2  pleasure 

3  poem 
1  poems 

7  poetry 
23  poor 

1  power 

1  psychology 

1  quick 

1  reading 

1  reason 

4  recall 

2  recalling 

8  recognition 
2  recollect 

16  recollection 
8  recollections 

1  reflect 

27  remember 

4  remembering, 
18.  remembrance 

2  remind 

1  reminder 

2  reminiscence 
1  reminiscences 
1  reproductive 
1  result 

1  retain 

2  retaining 

5  retention 

3  retentive 
1  retrospect 

1  sadness 
1  scenes 
1  scholar 

6  school 

1  sensation 

6  sense 

2  senses 

7  short 

1  simple 


5  meat 
1  meekness 
3  mountain 
60  mutton 

1  nature 

1  oxen 


2  park 
27  pasture 

3  pastures 

1  peace 
1  peaceful 
1  pet 
1  picture 

2  pig 
1  plains 
1  play 
4  pretty 

2  quadruped 

1  raising 
I  ram. 


1  song 

2  sound 

1  splendid 
1  stanza 
1  storehouse 
1  story 
1  strengthen 
1  strong 
1  student 
4  study 
1  studying 
1  sure 

7  sweet 
1  swift 
1  swing 

1  teacher 

1  tender 

6  test 

1  thankful 

1  things 
&'?  think 
"JS  thinking 

1  thinks 
81  thought 
28  thoughts 

8  thouglvtful 

8  thoughtfulness 
1  thoughtlessness 
1  time 
1  train 
1  training 
1  tree 

1  unconsciousnefj 
8  understand 
6  understanding 

1  unstable 

2  useful 

2  verses 

1  weak 
1  well 
1  will 
1  wit 

1  wonderful 

2  work 

2  youth 


1  rocks 
1  run 
1  running 

1  shear 
1  ■shearing 
1  shears 
15  shepherd 
1  simple 

1  sleep 

2  small 
1  soft 

1  spring 

2  stock 
1  stupidi 

1  tick 
1  trust 

i  wander 

1  water 
18  white 

2  wolf 
148  wool 

10  woolly 


FREQUENCY  TABLES 


585 


63.  BATH 

Ibaby 

1  dry 

2  invigorating 

2  pleasure 

1  springs 

1  basin 

2  plenty 

10  swim 

2  bathe 

1  English 

1  joy 

3  plunge 

5  swimming 

6  bathing 

1  CTery 

1  porcelain 

1  beneficial 

1  large 

1  take 

1  boat 

1  mth 

1  luxury 

1  refreshed 

1  taken 

1  boy 

1  filthiness 

6  refreshing 

2  toilet 

1  fine 

1  man 

1  refreshment 

6  towel 

120  clean 

1  flowers 

1  massage 

2  river 

2  towels 

1  cleaning 

1  fluid 

2  morning 

3  robe 

71  tub 

109  cleanliness 

2  fresh 

6  room 

2  cleanly 

1  nakedness 

1  vapor 

9  cleanness 

7  good 

1  neatness 

1  salt 

1  vessel 

6  cleanse 

6  necessary 

1  sanitary 

8  .cleansing 

9  health 

2  nice 

1  scrub 

1  want 

14  cold 

1  healthful 

1  none 

1  sensation 

3  warm 

3  comfort 

1  healthiness 

3  shower 

102  wash 

3  cool 

4  healthy 

6  ocean 

1  sleeping 

16  washing 

1  Creal    Springs 

10  hot 

1  often 

13  soap 

339  water 

4  house 

1  once 

1  soothing 

5  wet 

1  delight 

1  sponge 

1  wood 

4  dirt 

1  invigorates 

3  pleasant 

4  spray 

5  dirty 

2  yesterday 

2  abode 
1  agreeable 
1  alone 

1  apartments 

2  bam 
1  beach 

1  beautiful 
1  box 

3  brick 

1  brook 

2  brown 
31  building 
13  bungalow 

3  cabin 

1  camp 

2  camping 

1  Cape   Cod 

2  castle 
1  chair 

1  cheese 

3  city 

15  comfort 

2  contentment 

1  cottage 
36  country 

2  couple 
.2  cozy 

1  cute 

1  distant 


2  door 
23  dwelling 

2  family 
1  far 
4  farm 

1  fence 

6  field 

2  fine 

4  flowers 

2  frame 

7  garden 

3  green 

1  habitable 
3  habitation 
1  hamlet 
1  hammock 
1  handsome 

5  happiness 
1  happy 

3  hill 
85  home 
1  homelike 
1  homestead 
1  hope 
1  hospital 
461  house 
1  houses 

1  innocence 


64.  COTTA6B 

1  ivy 

5  lake 
1  lane 
1  large 
4  lawn 
4  little 

17  live 

6  living 
Hog 

1  lonesomenesa 
4  love 

2  low 

1  lumber 

1  Maine 
15  mansion 

1  name 

3  neat 

1  Newburgh 

4  nice 

2  one 
1  open 

1  orrhard 
1  outing 

1  painted 

2  palace 

2  parsonage 
1  patient 


1  patients 

1  peace 

1  people 

1  picturesque 

1  place 

1  pleasantness 

1  pleasure 

1  pond 

4  porch 

1  prettiness 

3  pretty 

1  pudding 

1  reside 

4  residence 
1  resident 
1  resort 

3  rest 
1  river 
1  rod 
3  roof 

1  roomy 

2  roses 
1  rustic 

1  scliool 
10  sea 

5  seashore 

2  seaside 

6  shelter 
2  shingles 
2  shore 


1  simplicity 
1  sleep 
30  small 
1  snug 
1  stands 

3  structure 
9  summer 
1  sweet 

1  Switzerland 

1  table 

4  tent 

2  thatchea 
1  tower 

1  trees 

3  two 

1  unity 

2  vacation 
1  veranda 
1  villa 

3  village 

1  vine 
3  vines 

3  white 

2  window 
1  woman 

11  wood 
1  wooden 

3  woods 

1  yard 


586 


FREE  ASSOCIATION  TEST 


2  active 

7  deer 

2  aeroplane 

1  degree 

1  ahead 

1  doctor 

1  antelope 

2  dog 

13  arrow 

11  automobile 

8  eagle 

1  autos 

2  easy 

3  engine 

6  ball 

1  beauty 

222  fast 

1  better 

1  fastness 

1  bicycle 

1  fear 

16  bird 

1  fish 

1  birds 

5  fleet 

1  boat 

6  flight 

1  brisk 

8  fly 

1  brook 

3  flying 

3  bullet 

1  foot 

1  cat 

1  girl 

1  channel 

1  go 

1  child 

1  going 

1  choice 

1  good 

1  clever 

1  grand 

1  creek 

1  Greek 

V  current 

1  curve 

1  hard 

1  cutting 

1  hare 

I  haste 

65.   S"WIFT 

1  hear 

1  high 
28  horse 
12  hurry 

1  hurrying 

1  Indian 
1  kite 

1  launch 

1  lazy 

2  light 

4  lightning 

3  lively 

1  man 

1  Marathon 
1  Mercury 
1  messenger 
1  meteor 
1  more 

1  morning 

2  motion 

1  motoring 

2  movement 
1  moving 

1  muscles 


1  near 

1  Niagara  Falls 

1  power 

117  quick 
13  quickly 

5  quickness 

1  quiet 

6  race 
27  rapid 

2  rapidity 
2  rapidly 
1  real 

1  riding 

18  river 
1  rivers 
1  road 

1  rocket 

19  run 

20  running 
13  runner 

1  noshing 

1  sail 
1  sharp 
1  shot 
1  sleigh 
190  slow 


4  slowly 

IS  smart 

1  smartness 

3  smooth 

29  speed 

1  speedily 

1  speeding 

7  speedy 

1  spinchiled 

2  spry 

1  steam 

1  sting 

1  stone 

8  stream 

2  strong 

2  sure 

5  swallow 

1  swallows 

1  throw 

2  tide 

1  time 

18  train 

1  trains 

1  walking 

11  water 

8  wind 

1  work 

66.  BLrs: 


I  air 

1  azure 

1  ball 
1  beautiful 
1  becoming 
1  bell 
1  binding 
5  bird 
38  black 
1  blood 
1  blossom 
1  blotter 

1  bluebird 

2  bluing 
1  blusey 
1  book 

5  bright 
8  brown 

1  cadet 
1  chemical 
1  clock 
7  cloth 

3  clothes 

1  clothing 
1  cloud 


1  cold 
266  color 

2  colors 

2  coloring 

1  dainty 
24  dark 

5  deep 
1  depth 

18  dress 
1  dull 

1  ether 

6  eyes 

1  fair 
4  feeling 
1  fidelity 
6  flag 

3  flower 

1  forget-me-not 

1  gentian 

1  globe 

2  gloominess 
2  gloomy 

1  glum 


1  good 

2  grass 
10  gray 
54  green 

1  hat 

5  heaven 

2  heavens 
1  heavenly 
1  homesick 
1  hopeful 

1  horizon 
1  house 
1  hue 

5  indigo 

6  ink 

1  lake 
8  light 
1  lily 

1  lonesome 

2  melancholy 
1  Monday 

1  navy 


1  necktie 
12  ocean 

3  paint 
1  pale 
1  paper 

1  pencil 
9  pink 

2  pleasant 
1  pleasing 

1  policeman 

4  pretty 

1  purity 

2  purple 

54  red 
1  restful 

3  ribbon 
1  river 

1  room 

2  sad 

1  sailor 
7  sea 

1  serge 

2  shade 


1  sMes 
239  sky 

1  soft 

1  somber 
'  1  space 

1  stripes 

1  suit 

2  tie 

1  tint 

7  true 

2  truth 

1  turquoise 

1  unhappy 
1  unrest 

1  velvet 

2  violet 

3  violets 

2  washing 

8  water 
47  white 

2  wind 

2  Yale 
27  yellow 


6T.    HUNGRY 


1  aching 
1  ambitious 

1  angry 

2  animal 

1  appeasing 
57  appetite 


2  appetizing 

2  baby 

3  bad 

1  bananas 
1  bear 


4  beggar 

1  candy 

1  crackers 

1  biscuit 

5  child 

i  crave 

6  boy 

5  children 

7  craving 

26  bread 

4  cold 

1  cupboard 

S  breakfast 

1  college 

1  butcher 

1  country 

Idark 

FREQUENCY  TABLES 


587 


1  desirable 

il  desire 
1  devil 
1  devour 

31  dinner 
1  disagreeable 
4  discomfort 
1  displeasure 
1  dissatisfaction 
1  dissatisQed 
1  distress 

14  dog 
1  dogs 

1  dry 

126  eat 
64  eating 

2  eatables 

1  emotion 

4  emptiness 
13  empty 

2  exhausted 

9  faint 
1  fainting 

5  famine 
1  famish 

11  famished 
1  famishing 
1  fascinating 

3  fast 

6  fasting 


4  fatigue 
1  fatig^ued 
4  fed 
1  feel 

8  feeling 
1  fill 

4  filled 
130  food 
1  form 
1  fulfilment 

9  full 
3  fruit 

1  gaunt 
1  Gertrude 

1  girl 

2  gnawing 
1  good 

1  grrub 

1  hardship 
1  Henrietta 
1  hog 

1  horse 

2  hunger 

3  I 

1  ice-cream 

1  kitchen 

2  lack 


1  lion 
5  longing 

4  lunch 

5  man 

4  me 

1  meal 
3  meat 

1  milk 

2  miserable 
1  misery 

1  nausea 

1  necessary 

2  need 
1  needy 
1  never 
1  nice 

1  no 
1  noon 
1  nothing 

1  nourish 

2  now 

I  ocean 
1  often 

5  pain 

1  painful 
1  pallid 
1  pang 
1  peaches 


1  perishing 

2  person 
2  picnic 
2  pie 

2  plenty 
1  plow 
6  poor 

1  potatoes 

2  poverty 
1  present 

1  ravenous 
1  repletion 

1  sad 

2  sandwiches 

3  satiated 
2  satiety 

14  satisfied 
2  satisfy 

1  school 
1  sensation 
1  sharp 
1  ship 
1  sick 
1  sleepy 

1  slow 

2  sorrow 

10  starvatiot 
8  starve 

15  starved 
29  starving 


2  steak 
13  stomach 
1  suffering 
1  sufficiency 

1  suflScient 

2  supper 

1  table 
12  thirst 
61  thirsty 

1  thought 

1  tiger 
12  tired 

1  tiresome 

3  tramp 

1  traveling 

1  uncomfortable 
1  unhappineaa 

4  unhappy 

4  unpleasant 
3  unsatisfied 

X  very 
1  viands 
1  victuals 

1  walk 
25  want 

5  wanting 
5  weak 

3  weakness 

2  wish 
10  wolf 


68.    PRIEST 

3  altar 

1  conscientious 

2  heaven 

12  nun 

8  robes 

1  authority 

1  console 

1  high 

1  ruler 

1  counsellor 

3  holiness 

1  office 

1  belief 

1  crucifix 

15  holy 

11  parson 

11  pastor 

1  people 

3  person 
1  piety 

4  pious 
3  Pope 
1  power 
1  praise 
3  pray 

1  prays 
8  prayer 

1  prayers 
3  preach 

2  preaches 
35  preacher 

2  prelate 

2  priestess 
1  profession 

3  prophet 

1  pulpit 

2  purity 

2  sacred 

3  Bible 

2  honor 

1  sacrifice 

6  bishop 

1  dignified 

2  hood 

1  sanctity 

13  black 

2  discipline 

1  house 

1  school 

1  blessing 

1  discontent 

1  humble 

1  sent 

1  book 

1  dishonor 

2  hypocrite 

1  serious 

1  boy 

1  dislike 

3  sermon 

1  brother 

1  divine 

1  inspired 

1  sermony 

1  divinity 

1  instruction 

2  servant 

1  cassock 

5  doctor 

2  service 

2  cathedral 

1  doing    ■ 

2  Jew 

1  services 

36  Catholic 

1  dominie 

1  just 

2  shaven 

2  Catholics 
4  Catholicism 

1  dress 
1  Dr.    K. 

1  justice 

1  shoot 
1  sinner 

1  ceremony 

1  duty 

1  kind 

1  sister 

1  chancel 

1  knowledge 

1  slim 

2  chapel 

1  exalted 

1  solemnity 

1  childhood 

2  layman 

1  sometimes 

1S6  church 

2  faithful 

4  leader 

1  spookism 

1  clean 

2  fakir 

1  lecture 

1  stern 

SO  clergy 

1  fakirs 

1  Levi 

1  student 

62  clergyman 

3  fat 

2  Levite 

2  Sunday 

1  cleric 

15  father 

1  Lord 

3  surplice 

2  clerical 

1  follower 

2  rabbi 

1  cloister 

1  forgive 

5  male 

57  religion 

1  table 

1  cloth 

1  forgiveness 

75  man 

7  religrious 

2  teacher 

1  clothes 

5  mass 

1  representative 

1  collar 

2  garb 

178  minister 

1  repulsive 

1  ugly 

1  comforter 

1  gentleman 

5  monastery 

1  reserved 

1  command 

2  God 

9  monk 

1  reverend 

1  vest 

1  communion 

9  good 

1  moral 

2  righteous 

1  vicar 

5  confession 

1  goodness 

1  road 

2  confessor 

6  gown 

1  noble 

12  robe 

1  York 

588 


FREE  ASSOCIATION  TEST 


1  afraid 
1  sngry 
11  Atlantic 

1  barge 
3  bathing 
3  bay 
5  beach 
1  beautiful 

5  big 

1  bisTiess 
1  billows 
25  blue 

6  boat 

1  boats. 

2  body 

1  boisterous 

3  breadth 
1  breeze 

3  broad 
1  Byron 

1  Cape  Cod 

2  Coney  Island 
1  country 


1  croEsing 
1  current 

1  dark 
87  deep 

1  deepness 
10  depth 

1  depths 

2  distance 

1  enormous 

1  Europe 

2  expanse 

1  expansive 

1  float 

2  foam 

2  grand 

2  grandeur 

3  great 

1  greatness 

2  green 
2  Grove 
1  gulfs 


69.   OCEAN 

1  Hudson 

1  immense 

2  immensity 
2  infinity 

2  joy 

12  lake 

8  land 

9  large 

1  launch 
1  liquid 

1  Maine 

1  Mauretania 

1  might 

3  mighty 

2  motion 

1  power 
1  pretty 

1  quantity 

38  river 
1  roars 


12  rough 

2  sail 
2  sailing 

10  salt 

2  sand 

1  Sandy  Hook 
75  sea 

3  eeas 

2  seashore 
1  seething 

1  shining 
24  ship 

11  ships 

2  shore 
1  sky 

1  sound 
1  storm 
1  storms 
1  steamboat 
14  steamer 
1  steamers 
1  steamship 

4  stream 

1  swiftness 


2  swim 

1  swimming 

1  tide 

1  terrible 

1  traveling 

1  trip 

1  valley 

7  vast 

9  vastness 

2  vessel 

1  voyage 

1  waste 

127  water 

I  waters 

12  wave 

45  waves 

1  wavy 

2  wet 

1  white 

15  wide 

1  wonder 

1  wonderful 

70.  HEAD 


1  above 
9  ache 

1  aches 

8  anatomy 

2  animal 

1  appearance 

2  arm 

3  arms 

1  asymmetrical 

1  baby's 

2  back 
1  bald 
1  ball 

1  beautiful 

1  beginning 

5  big 

1  black 
146  body 

1  bonehead 

1  boss 
58  brain 
32  brains 

1  branch 

1  bright 

1  brown 

7  cabbage 

3  captain 

1  cattle 

2  cavity 
2  chest 
2  chief 
1  chop 
1  dear 
Z  comb 


1  combs 

1  consciousness 

1  cover 

1  covered 

2  cow 

11  cranium 
1  crown 

1  director. 
1  donkey 

1  ear 

1  ears 

1  emptiness 

1  empty 

1  encephalon 

1  end 

1  extremity 

2  eye 
10  eyes 

13  face 
1  father 

1  feature 

2  features 
26  feet 

1  figure 

1  firm 

2  first 
1  food 

64  foot 
1  forehead 
1  front 

Igirl 
1  glasses 


3  good 
1  govern 

1  great 

159  hair 
11  hand 

2  hands  • 

1  handsome 

2  hard 
17  hat 

1  headless 
8  heart 

2  heels 

3  high 

2  highest 
2  hot 
1  house 

4  human 


1  individual 

2  intellect 

3  intelligence 

1  king 

1  knee 

17  knowledge 

19  large 

1  leadership 

1  leading 

1  life 

2  light 

3  limb 

1  limbs 

1  little 

1  long 

1  louse 

14  man 

1  man's 
1  masterpiece 
1  medium 
7  member 
3  memory 
1  mentality 

14  mind 
1  mouth 

1  nail 

1  nation 
17  neck 

2  nose 

5  organ 

1  pain 

6  part 

1  people 

15  person 

2  physiology 
1  planning 

1  Pope 

3  power 

2  president 

1  pretty 

2  principal 
1  procession 

1  quarters 

2  rest 
21  round 

1  roundnraa 

3  ruler 


4  scalp 

3  sense 

1  senses 

1  sensible 

4  shape 

1  shaped 

1  shoulder 

12  shoulders 

5  skull 

7  small 

2  sore 

1  square 

2  statue 

2  stomach 

1  strong 

2  superintendent 

1  symmetry 

3  tail 

1  teeth 

2  thick 

9  think 

6  thinking 

16  thought 

4  thoughts 

1  tired 

81  top 

2  trunk 

2  useful 

1  whirl 
1  wit 

1  woman 

2  woman's 
1  work 


FREQUENCY  TABLES 


589 


71.  STOVE 

3  article 

1  dinner 

213  heat 

4  lid 

1  round 

1  dirt 

1  heating 

3  Ufter 

1  rusty 

1  bake 

1  dishes 

1  heats 

i  light 

1  baking 

6  heater 

1  long 

1  shovel 

69  black 

217  flre 

2  heavy 

1  sink 

4  blacking 

3  fireplace 

1  home 

2  metal 

2  small 

1  box 

1  flame 

86  hot 

1  smoke 

1  breakfast 

3  food 

2  house 

1  oil 

3  steel 

2  bright 

1  Franklin 

1  household 

1  oven 

1  structure 

12  burn 

1  fry 

2  burning 

1  fuel 

1  icebox 

1  painful 

1  teakettle 

6  furnace 

1  implement 

18  pipe 

1  chair 

8  furniture 

2  instrument 

1  pipes 

1  using 

1  chimney 

1  fumituieness 

61  iroti 

5  poker 

2  utensil 

25  coal 

1  isinglass 

10  polish 

2  comfort 

7  gas 

32  warm 

24  cook 

1  German 

4  kettle 

2  radiator 

42  warmth 

84  cooking 

2  good 

11  kitchen 

19  range 

1  water 

1  cooka 

1  grate 

1  receptacle 

2  winter 

3  cover 

3  lamp 

1  red 

7  wood 

2  hard 

2  large 

2  room 

1  dark 

1  hardware 

2  legs 

72.  I.ONG 

1  dnc 

1  age 

1  elongated 

7  large 

1  reed 

X  stupid 

1  anxiety 

1  endless 

1  lasting 

3  ribbon 

1  summer 

1  arm 

1  enough 

1  lecture 

1  ride 

1  arms 

2  eternity 

1  legs 

15  river 

3  table 

2  avenue 

1  extended 

60  length 

32  road 

26  tall 

1  away 

1  extension 

6  lengthy 

1  rod 

1  test 

1  extensive 

1  level 

1  room 

2  thin 

1  bam 

1  extent 

4  life 

7  rope 

2  thread 

1  beach 

5  line 

1  row 

1  throw 

1  bench 

8  far 

1  linear 

1  rug 

15  time 

1  big 

1  feet 

1  live 

2  rule 

1  tiresome 

1  blackboard 

1  fellow 

1  Lusitania 

4  ruler 

1  tower 

2  board 

2  fence 

3  track 

6  boat 

1  flagpole 

6  man 

1  shape 

2  train 

1  book 

1  foot 

7  measure 

1  sharp 

4  tree 

1  boulevard 

1  for 

2  medium 

1  shore 

1  trip 

1  bridge 

1  meter 

413  short 

2  broad 

2  giant 

13  mile 

1  shovel 

1  vast 

1  Brooklyn 

1  girl 

1  miles 

1  slender 

1  very 

Bridge 

2  glass 

1  Mississippi 

1  slim 

1  broomstick 

4  grass 

1  much 

1  slow 

1  wait 

1  building 

1  great 

1  small 

2  waiting 

1  name 

2  snake 

7  walk 

1  cable 

2  hair 

15  narrow 

1  something 

1  walking 

1  chimney 

2  haU 

2  night 

1  space 

1  walls 

1  coat 

1  head 

1  nose 

1  spacious 

6  way 

1  courage 

1  height 

1  spire 

1  ways 

1  craving 

5  high 

1  oblong 

1  square 

1  weary 

1  hill 

1  stay 

1  whale 

9  day 

Ihose 

2  path 

1  steamer 

1  whUe 

1  days 

1  hours 

1  person 

1  steeple 

7  wide 

1  deep 

1  house 

1  pin 

8  stick 

1  winter 

1  depth 

1  pipe 

1  sticks 

1  wire 

X  desirable 

2  Island 

1  plant 

2  story 

1  wishing 

I  dimensions 

1  plenty 

1  straight 

1  without 

81  distance 

8  journey 

20  pole 

6  street 

I  worm 

8  distant 

1  streets 

6  dress 

J  labor 

4  railroad 

1  strength 

4yard 

1  duration 

8  lane 

1  railway 

2  stretch 

2  yew 

2  lanky 

Irails 

6  string 

590 


FREE  ASSOCIATION  TEST 


73.    RBLIGION 


1  Abraham 

2  different 

1  honor 

1  obey 

2  science 

1  aesthetics 

1  difficult 

1  house 

3  opinion 

1  scripture 

1  aim 

1  dislike 

1  hypocrisy 

1  order 

8  sect 

1  all 

1  divine 

1  orthodox 

2  sectarian 

1  anything 

4  doctrine 

2  idea 

1  self 

1  association 

1  dogma 

1  ideas 

1  paganism 

3  service 

2  atheism 

2  doubt 

1  ignorance 

3  peace 

1  sheeney 

4  atheist 

1  Druids 

1  indefinite 

3  people 

1  society 

1  duties 

1  indiscreet 

1  perfect 

1  solace 

2  Baptist 

2  duty 

1  institutions 

1  persecution 

1  somewhat 

1  beauty 

1  irreligion 

2  person 

1  soul 

39  belief 

1  emotion 

1  irreligious 

3  persuasion 

1  spirituality 

1  beliefs 

4  Episcopal 

13  piety 

1  stability 

2  believe 

1  Episcopalian 

3  Jesus 

13  pious 

1  standby 

1  believing 

1  eternity 

3  Jew 

2  poor 

1  study 

1  believer 

2  ethics 

1  Jews 

1  Pope 

1  superstition 

1  belong 

1  everyday 

i  Jewish 

1  powerful 

1  belonging 

1  just 

2  practice 

1  tabernacle 

62  Bible 

Ifait 

2  pray 

1  table 

1  body 

47  faith 

2  kind 

2  praying 

1  teaching 

2  books 

1  fake 

1  knowledge 

21  prayer 

1  temperament 

8  brain 

2  fanatic 

6  prayers 

2  temple 

1  Buddha 

1  fanaticiam 

1  law 

2  prayer-book 

2  think 

1  feeling 

1  learning 

2  preacher 

1  thinking 

1  catechism 

1  fine 

4  life 

2  preaching 

12  thought 

56  Catholic 

2  foolish 

1  living 

3  Presbyterian 

1  thoughtful 

2  ceremony 

1  tree 

1  Lord 

28  priast 

1  training 

1  China 

1  Lutheran 

3  profession 

1  true 

8  Christ 

1  gentile 

1  professor 

1  trust 

14  Christian 

1  German 

1  man 

30  Protestant 

6  truth 

7  Christianity 

31  God 

1  men 

1  pulpit 

1  ChristUke 

1  godly 

1  mankind 

2  pure 

1  uncertain 

161  church 

48  good 

1  many 

1  puzzle 

1  uncertainty 

4  churches 

10  goodness 

1  mental 

1  unknowable 

1  churchman 

2  gospel 

1  Methodism 

1  question 

1  civilize 

1  government 

7  Methodist 

1  virtuous 

1  clererymaa 

3  guide 

15  minister 

1  race 

1  vow 

4  comfort 

1  modesty 

1  rector 

1  commandments 

3  happiness 

2  Mohammed 

2  religious 

1  want 

1  conduct 

1  harmony 

2  morals 

3  reverence 

1  wickedness 

1  Congregational 

1  health 

1  mystic 

2  right 

1  wide 

2  conscience 

3  heathen 

2  righteousneffl 

1  woman 

1  conversion 

8  heaven 

2  nationality 

1  wonder 

2  Creator 

1  Hebrew 

1  need 

1  sacrament 

1  wonderful 

33  creed 

2  helpful 

1  no 

4  sacred 

1  work 

1  custom 

1  hereafter 

5  none 

1  sacredness 

14  worship 

1  heresy 

2  nothing 

1  saintly 

1  worshipping 

1  deep 

2  history 

1  nun 

1  saints 

11  denomination 

4  holiness 

1  nuns 

2  salvation 

1  Yankee 

4  devotion 

10  holy 

1  scholastic 

74.    "WHISKEY 


1  abomination 

24  brandy 

1  deviltry 

2evU 

Shot 

60  alcohol 

1  breath 

1  Dewar's 

1  hotels 

1  ale 

1  bum 

1  disagreeable 

1  fast 

1  Himter 

1  amber 

4  burning 

1  discontent 

4  fire 

1  appetizfit 

1  disgust 

1  flask 

1  Indulge 

1  apple 

1  Carrie  Nation 

1  distillery 

4  fluid 

1  indulgence 

1  awful 

8  cider 

1  distress 

1  food 

1  inebriety 

1  closet 

1  dope 

1  full 

1  insanity 

85  bad 

1  color 

1  dreadful 

5  intemperance 

1  barley 

1  com 

232  drink 

8gin 

13  intoxicant 

2  barrel 

4  curse 

1  drinks 

3  glass 

2  intoxicants 

1  bed 

17  drinking 

15  good 

3  Intoxicated 

46  beer 

1  dangerous 

1  drinkable 

1  grain. 

14  intoxicating 

9  beverage 

1  dark 

1  drug 

14  intoxication 

1  biting 

1  death 

81  drunk 

1  hard 

6  bitter 

1  degradation 

18  dnmkard 

1  headache 

Ijag 

10  booze 

1  despised 
1  destruction 

8  drunkards 

1  Heimessey'fl 

1  Boston 

28  drunkenneas 

1  hops 

1  Kentucky 

29  bottle 

1  devU 

1  horror 

1  knock 

FREQUENCY  TABLES 


591 


1  law 

1  odor 

1  ruin  - 

5  spirit 

1  terrible 

12  liquid 

1  old 

1  ruination 

23  spirits 

1  thirst 

1  liquids 

23  rum 

38  stimulant 

1  thirsty 

70  liquor 

I  pint 

9  rye 

4  stimulants 

1  tipsy 

1  place 

1  stimulating 

1  toddy 

2  malt 

1  pleasant 

15  saloon 

1  stimulation 

1  toper 

2  man 

4  poison 

1  saloons 

1  stomach 

2  trouble 

4  medicine 

1  poor 

1  Scotch 

2  straight 

1  misery 

1  poorhouse 

1  seasickness 

6  strong 

1  unhealthy 

1  money 

1  powerful 

2  sick 

1  stupidity 

1  unpleasantness 

1  moonshine 

2  prohibition 

2  sickness 

1  suffering 

1  punch 

2  smell 

1  warm 

3  narcotic 

1  smuggle 

1  taste 

9  water 

2  nice 

1  rarely 

1  sorrow 

4  temperance 

18  wine 

1  none 

2  red 

4  sour 
75.   CniLD 

1  temptation 

1  vrong 

5  adult 

1  darling 

l.hair 

8  love 

1  precocious 

3  angel 

2  daughter 

2  happiness 

2  loving 

10  pretty 

1  dear 

2  happy 

4  lovely 

1  pupil 

7  babe 

1  dearest 

1  healthy 

1  pure 

193  baby 

1  delight 

1  helpless 

1  male 

1  purity 

1  bad 

1  disobedient 

1  helplessness 

1  mammal 

8  beautiful 

1  dog 

6  home 

41  man 

1  rattle 

5  beauty 

4  doll 

2  hood 

1  maternity 

1  religious 

8  being 

4  dress 

1  hospital 

1  me 

2  birth 

1  dresses 

5  human 

1  mite 

5  school 

2  blessing 

1  humanity 

55  mother 

1  screaming 

2  body 

1  Eleanor 

1  motherhood 

1  senses 

1  born 

1  Elizabeth 

1  ill 

1  simple 

64  boy 

1  embrj'onic 

1  immature 

1  naive 

1  simplicity 

3  boj's 

1  expectation 

1  infancy 

1  naughty 

1  sister 

1  burden 

122  infant 

1  necessary 

52  small 

2  family 

1  injury 

1  nephew 

1  smile 

1  care 

1  fat 

16  innocence" 

1  nice 

2  son 

1  carriage 

5  father 

11  innocent 

1  night-dress 

1  spoiled 

1  charm 

3  female 

1  instinct 

1  noise 

1  study 

1  childhood 

1  frolicsome 

2  interesting 

2  nuisance 

6  sweet 

1  childish 

2  fun 

2  sweetness 

1  Christ 

1  fussy 

1  joy 

1  obedient 

1  clothes 

1  future 

2  juvenile 

6  offspring 

1  table 

8  comfort 

1  tender 

1  coming 

45  girl 

4  kid 

6  parent 

1  three 

1  companion 

2  girls 

J  kindergarten 

1  parents 

1  toys 
1  trouble 

2  cradle 

1  glass 

3  people 

1  creep 

7  good 

2  labor 

18  person 

3  weak 

1  crib 

1  eoose 

2  lady 

1  pet 

18  woman 

1  cries 

1  Greta 

2  large 

14  play 

4  cry 

1  growing 

1  like 

3  plaving 

30  young 

1  cross 

1  growth 

11  little 

3  plavful 

2  youngster 

1  cunning 

1  lonely 

4  pleasure 

29  youth 

3  cute 

1  habits 

1  lovable 

1  plump 

1  youthful 

76.    BITTER 


8  acid 

5  beer 

1  disappointment 

1  grudge 

1  limes 

1  acrid 

1  berry 

2  dislike 

1  liquor 

1  agreeable 

1  biting 

10  distasteful 

2  hatred 

1  love 

1  ale 

1  boneset 

1  dregs 

2  herb 

4  almond 

1  burdock 

2  drink 

5  herbs 

1  magen 

3  almonds 

1  hops 

1  man 

4  aloe 

1  candy 

2  enemy 

3  horrid 

1  mandrake 

6  aloes 

1  cascara 

1  horseradish 

37  medicine 

1  altogether 

1  chastisement 

1  feelings 

1  Mirabar 

2  alum 

1  chickory 

1  flag 

1  icy 

1  morphine 

3  aneer 

1  chocolate 

4  fruit 

1  ill 

3  nasty 
1  nice 

3  apple 

1  cider 

1  irritating 

1  apples 

6  cold 

42  gall 

1  none 

1  apricot 

1  cross 

2  good 

8  lemon 

1  nux 

1  astringent 

1  cup 

1  grape 

1  lemony 

3  grapefruit 

1  lemonade 

1  offensive 

10  bad 

1  deep 

1  grass 

1  lessons 

1  olives 

1  banana 

10  disagreeable 

2  grief 

1  life 

3  orange 

592 


FREE  ASSOCIATION  TEST 


1  peacb 

1  peel 

9  pepper 

2  persimmoD 

3  pickle 
1  pickles 
1  pleasant 

4  plums 
1  poison 
3  pucker 

1  puckering 

I  quassUt 


1  quince 

1  spice 

1  tear? 

1  unpleasantness. 

23  quinine 

3  stroner 

1  temper 

1  unsweetened 

1  strychnia 

3  thoroughwort 

1  unwholesome 

1  rank 

4  strychnine 

1  thought 

1  suffering 

1  tonic 

1  vegetables 

1  sadness 

305  sweet 

2  tonics 

17  vinegar 

2  salt 

1  sweeter 

1  trouble 

2  salts 

1  turnip 

1  water 

3  sharp 

8  tart 

1  weather 

8  sorrow 

66  taste 

8  ugly 

1  wine 

1  sound 

3  tasteless 

1  unhealthy 

1  word 

222  sour 

1  tasting 

1  unpalatable 

2  words 

2  soumew 

1  tea 

19  unpleasant 

2  wormwodd 
1  wrong 

77.   HAHMEB, 


2  action 

5  driving 

1  knife 

1  plumber 

4  striking 

1  annoyance 

1  door 

35  knock 

61  pound 

1  stroke 

6  anvil 

6  knocker 

12  pounding 

1  article 

1  easy 

5  knocking 

1  pounds 

3  tack 

1  awl 

1  effort 

11  tacks 

11  axe 

2  large 

1  rap 

1  Thor 

3  finger 

1  lost 

1  repairs 

1  thread 

3  bang 

2  force 

1  revolver 

6  throw 

1  beating 

3  mallet 

1  road 

1  throwing 

2  blacksmith 

1  geology 

1  mark 

1  rod 

1  thumb 

6  blow 

1  maul 

1  round 

1  thump 

2  board 

5  handle 

1  metal 

1  toe 

1  bruiser 

63  hard 

9  saw   . 

29  tongs 

2  building 

6  hatchet 

185  nail 

1  scissors 

69  tool 

2  head 

98  nails 

1  shoemaker 

3  toola 

13  carpenter 

13  heavy 

2  nailing 

1  shop 

1  turf 

1  carpentering 

21  hit 

86  noise 

10  sledge 

10  chisel 

1  horseshoe 

1  nut 

2  small 

1  use 

1  claps 

1  hurt 

1  nuts 

9  sound 

5  useful 

1  claw 

1  hurts 

1  spade 

1  utensil 

2  club 

2  one 

1  stay 

1  concussion 

8  implement 

20  steel 

3  weapon 

1  convenience 

38  instrument 

1  pain 

1  stone 

3  weieht 

45  iron 

2  picture 

1  strength 

6  wood 

17  drive 

1  pictures 

28  strike 

8  work 

1  drives 

2  J. 

2  working 

78.    THIRSTY 


lall 

1  desiring 

1  glass 

1  nauseated 

1  suffering 

2  always 

1  dipper 

1  good 

1  animal 

1  disagreeable 

1  oranges 

1  terrible 

3  appetite 

2  discomfort 

1  hard 

1  throat 

2  doff 

1  haste 

2  pain 

1  tongue 

Ibar 

206  drink 

2  heat 

3  parched 

A  beer 

23  drinking 

1  horse 

2  parching 

1  uncomfortable 

1  beverage 

8  drought 

2  hot 

1  people 

2  unpleasant 

Ibird 

218  dry 

9  hunger 

1  person 

1  boy 

6  dryness 

41  hungry 

1  verv 

1  brooks 

12  quench 

1  vichy 

1  emotion 

1  labor 

4  quenched 

1  cattle 

1  empty 

2  1afk 

2  walk 

2  child 

1  exhausted 

1  lawn 

1  refreshing 

9  want 

1  cold 

7  lemonade 

2  wanting 

4  craving 

1  famished 

1  liquid 

1  satiated 

1  warm 

1  cream 

1  fatisiTie 

4  longing 

3  satisfied 

841  water 

2  cup 

6  feeling 

1  sensation 

1  wench 

1  fluid 

1  man 

2  soda 

3  wet 

2  desert 

1  food 

2  mouth 

8  spring 

2  work 

4  desire 

1  (ountaia 

1  etream 

FREQUENCY  TABLES 


593 


1  Albany 

1  beautifcil 
9  big 

5  Boston 
1  bridges 

3  Brooklyn 

6  building 
20  buildings 

1  hulk 

1  Burlington 

1  business 

4  busy 

2  bustle 

6  capital 

3  cars 

1  charming 

4  Chicago 
1  child 

7  citizen 

1  civilization 

1  Cleveland 

2  cojlection 

5  community 
1  complexity 
1  confusion 

1  congregation 

2  corporation 
74  country 


1  acctirate 
1  acre 
1  across 
1  active 
1  airy 
H  angle 
6  angles 
4  angular 
1  arithmetic 
1  aasociation 

Ibed 

1  best 
Ibig 

71  block 
4  board 

4  bools 
86  box 

2  brick 

5  broad 

2  building 
1  business 

9  carpenter 
1  carpet 

1  cars 

2  center 

1  Chatham 
1  checkers 
22  circle 
1  cirCTilar 
4  city 
1  Common 
1  Commons 

6  compass 
1  concert 

1  Copley 

7  comer 
18  comers 

2  cornered 
1  correct 

1  corTectney 
1  cover 


1  Creal 

I  Creal  Springs 
11  crowd 
7  crowded 
1  crowds 

1  density 
1  dirt 
1  distance 

1  earth 

1  excitement 

1  fine 
1  fun 

1  gaiety 

1  good 

1  government 

1  governor 

2  great 

1  greatness 

3  habitation 

1  heat 

2  hill 

6  home 
1  homes 
1  hot 


1  crackers 

8  crooked 
1  crowd 

9  cube 
1  cubic 

1  cubical 
1  curse 
1  curve 

1  deal 
1  dealing 

1  decoration 

2  desk 

1  Dewey 
4  dice 
Idle 

2  door- 

1  DOsseldort 

1  earth 
1  ease 
6  equal 
19  even 
1  evenness 
1  exact 

3  (air 

4  field 
4  figure 
1  file 

4  flat 

1  floor 

2  foot 
1  form 

10  four 
1  frame 
1  furlong 

6  garden 

10  geometry 
1  Getty 

1  goo<^ 
1  grass 


79.   CITY 

3  house 
62  houses 

1  immense 
1  incorporated 

1  incorporation 

2  industry 

1  inhabitant 
12  inhabitants 
1  inhabited 

1  joy 

2  land 
62  large 

1  largeness 

2  life 
7  live 

1  loathing 

2  location 
1  lots 

1  machinery 
1  majority 

1  Manhattan 

2  manufacture 

3  many 
2  men 

6  metropolis 


60.   s  air  are: 

3  green 
1  grounds 

1  hand 

2  handkerchief 

1  Harlem 

2  Herald 
1  heavy 

3  honest 

1  honesty 
5  house 

3  houses. 

2  inch 

1  inches 
1  instrument 
1  iron 

1  just 

2  justice 

1  junction 

1  kindergarten 

1  knob 

2  land 
5  large 

1  Lawrence 

2  length 
10  level 

2  lines 
1  little 
18  long 
1  lot 

12  Madison 
5  man 
1  mark 
1  marks 

1  masonry 

2  mathematics 

1  meal 

5  measure 

2  measweoient 


Imill 
1  mountain 
1  municipal 
1  municipality 

1  nation 
99  New  York. 
12  noise 

0  hoisy 

1  park 

1  pavement 
48  people 
37  place 

1  pleasantness 

2  populated 
19  population 

1  populous 

6  Poughkeepsie 

2  republic 
2  residence 
1  resting 

1  rich 

1  scene 

1  sea 

1  settlement 

1  shopping 

li" 


1  sights 
1  sin 
1  size 
1  slums 
1  small 

1  smoke 

2  space 

1  Springfield 
26  state 
1  stores 

3  street 
11  streets 

1  tale 

1  ten  thousand 

2  theatre 

1  theatres 

2  towers 
258  town 

1  towns 
1  township 
1  traffic 
1  traveling 

1  tumult 

2  turmoil 

44  village 

1  wagoiw 
1  welcome 
I  world 


1  measturements 

1  metal 

2  mile 

1  monument 

1  New  York 

2  object 
32  oblong 

1  obtuse 
1  open 
6  oval 

6  paper 
1  parallel 
1  parallelogram 
14  park 

1  pavements 

2  people 


2  sharp 
1  side 
6  sides 
1  sidewalk 
1  size 
1  sizing 

6  small 

1  smooth 

2  solid 

1  space 

2  stand 
1  steel 

7  straight 
9  street 

1  streets 
1  sugar 
1  surface 
1  surveyor 


2  perfect 

47  table 

1  picture 

1  thoroughfsre 

2  pillow 

3  Times 

4  place 

13  tool 

1  plane 

1  tree 

1  plot 

4  trees 

1  proportion 

11  triangle 

2  public 

1  true 

1  quadrangle 

1  uneven 

15  rectangle 

1  uniform 

3  rectangular 

4  Union 

1  rhomboid 

2  upright 

5  right 

1  Rittenhouse 

8  village 

1  road 

1  walk 

5  room 

1  walks 

250  round 

1  wall 

9  rule 

4  Washington 

S  ruler 

2  wide 

1  window 

1  saddle 

5  wood 

1  seat 

6  shape 

2  yard 

594 


FREE  ASSOCIATION  TEST 


81.    BUTTER 


2  bad 

5  dish 

2  goat 

101  milk 

1  smooth 

2  bill 

1  dripping 

14  good 

1  molasses 

65  soft 

2  biscmt 

76  grease 

1  mush 

2  softness 

J06  bread 

34  eat 

6  greasy 

1  sour 

1  breakfast 

12  eatable 

1  grocer 

1  nourishment 

1  spoon 

1  butter 

2  eatables 

2  nut 

3  spread 

1  butterine 

6  eating 

1  healthful 

1  square 

1  edible 

9  oil 

2  strong 

41  cheese 

2  egg 

1  indifference 

3  oily 

1  substance 

4  chum 

11  eggs 

1  ingredients 

5  oleomargarine 

i  sugar 

1  color 

1  emollient 

1  supper 

1  composition 

1  excellent 

3  jam 

1  peaches 

12  sweet 

1  cooking 

2  jelly 

3  plate 

1  cottolene 

1  farm 

1  pleasant 

2  table 

1  country 

1  farmer 

1  kerosene 

1  plenty 

1  tallow 

1  cup 

21  fat 

7  knife 

1  pound 

2  taste 

29  cow 

1  fatty 

1  pure 

2  tea 

H  cows 

1  fish 

15  lard 

1  thin 

34  cream 

1  flour 
7  fly 

1  luxury 

2  rancid 

1  tub 

4  dairy 

63  food 

1  meal 

13  salt 

1  use 

1  dairying 

3  fresh 

2  meat 

3  salty 

3  vegetable 

2  diet 

1  fudge 

1  melt 

1  salve 

2  dinner 

2  melting 
82.   DOCTOR 

1  smear 

80  yellow 

1  administer 

6  disease 

5  ill 

1  murder 

1  qnack 

3  aid 

1  diseases 

21  illness 

1  ailment 

1  Divinity 

2  inquisitive 

1  N. 

6  relief 

1  apparatus 

1  doctress 

2  intelligent 

1  N. 

1  relieved 

2  attendant 

1  dog 

1  interne 

2  necessity 

1  remedy 

1  driving 

1  invalid 

1  need 

Ibad 

1  Dr.   P. 

1  needed 

IS. 

1  bag 

2  druggist 

IK. 

1  needful 

5  satchel 

2  beard 

1  K. 

1  nice 

Z  science 

2  better 

2  education 

1  killer 

41  nurse 

1  scientist 

Sbill 

1  kind 

1  nurses 

52  sick 

2  bills 

2  fakir 

104  sickness 

1  bottle 

3  false 

1  labor 

1  O. 

3  smart 

1  brains 

2  father 

1  laboratory 

1  office 

1  student 

1  brother 

3  friend 

1  laborer 

lold 

1  suffering 

1  butcher 

1  lamp 

1  one 

1  supervisor 

1  G. 

36  lawyer 

1  operation 

5  surgeon 

1  C. 

1  G. 

1  learned 

1  surgical 

10. 

1  gentleman 

1  life 

1  P. 

1  syringe 

2  care 

17  ffood 

2  pain 

2  carriage 

1  goodness 

1  M. 

1  papa 

1  tend 

1  case 

1  great 

1  McC. 

23  patient 

1  treatment 

1  chief 

2  grip 

1  McM. 

1  patients 

3  trouble 

1  clergyman 

1  niaglstrave 

1  people 

1  trust 

1  clever 

5  healer 

1  male 

3  person 

1  college 

2  healing 

68  man 

1  pharmacist 

2  useful 

1  convenient 

18  health 

1  mean 

1  phj-sical 

1  useless 

9  cure 

3  help 

19  medical 

213  physician 

1  helper 

149  medicine 

1  pills 

1  W. 

ID. 

1  helpful 

1  medicines 

2  practitioner 

1  W. 

1  D. 

1  helpfulness 

1  merchant 

6  priest 

1  w. 

1  D. 

1  home 

7  minister 

9  profession 

1  well 

1  death 

8  hospital 

1  mister 

3  professional 

1  wise 

6  dentist 

1  money 

2  woman 
1  work 

FREQUENCY  TABLES 


595 


83.   LOUD 

3  angry 

3  disagreeable 

2  laugh 

1  power 

2  sounds 

1  audible 

1  discontent 

2  laughing 

3  speak 

1  dislike 

2  laughter 

32  quiet 

2  speech 

1  band 

3  drum 

1  lofty 

1  quietness 

2  spoken 

1  bawl 

3  long 

7  still 

5  bell 

3  ear 

57  low 

1  racket 

1  stone 

2  bells 

12  easy 

1  real 

8  strong 

2  birds 

4  explosion 

1  man 

1  report 

1  subway 

38  boisterous 

1  masculine 

2  rough 

1  sweet 

1  boy 

3  fast 

1  megaphone 

2  rude 

2  boys 

1  forte 

1  mellow 

12  talk 

1  bright 

1  mild 

1  S. 

1  talking 

1  game 

1  mouth 

9  scream 

9  talker 

2  call 

1  gong 

7  music 

2  sharp 

9  thunder 

1  called 

1  graphophone 

1  shock 

1  tie 

1  calliope 

2  gun 

205  noise 

6  shout 

1  tone 

1  calm 

1  guns 

112  noisy 

1  shouting 

1  trolley 

12  cannon 

1  shriek 

1  check 

2  hammer 

1  objectionable 

9  shrill 

1  uncomfortable. 

I  child 

2  hard 

1  ocean 

1  shrinking 

5  unpleasant 

1  children 

3  harsh 

1  organ 

3  silent 

1  city 

1  haughty 

1  owl 

1  sing 

27  voice 

1  clear 

6  hear 

1  singer 

1  voices 

2  course 

1  heard 

1  pain 

1  singing 

4  vulgar 

2  color 

4  heavy 

1  painful 

4  slow 

1  common 

14  high 

1  people 

1  smart 

2  whisper 

1  confusion 

1  hog 

2  person 

1  smooth 

17  whistle 

1  cornet 

16  holler 

1  phonograph 

1  socks 

1  wide 

4  horn 

2  piano 

165  soft 

3  wind 

1  deaf 

1  impatient 

1  piercing 

1  soJfly 

1  deafening 

1  pistol 

2  song 

3  yell 

1  din 

2  knock 

1  pistols 
84.   THIEF 

25  sound 

2  yelling 

1  absence 

1  dishonor 

1  laugh 

1  pocketbook 

212  steal 

1  abstractor 

1  dislike 

4  law 

8  police 

69  stealing 

1  anger 

1  distrustful 

1  lawyer 

12  policeman 

8  steals 

1  arrest 

1  dirt 

6  liar 

1  poor 

9  stole 

1  dog 

7  lock 

6  prison 

9  stolen 

14  bad 

1  dumb 

3  loss 

1  prisons 

2  stealer 

1  badness 

2  low 

1  prisoner 

1  stealth 

1  bandit 

1  enemy 

2  punishment 

2  stealthy 

1  bank 

1  evil 

29  man 

1  purse 

3  beffcar 

1  mask 

5  take 

1  being 

2  fear 

1  McClure's 

1  ran 

3  taking 

1  betrayer 

1  felon 

4  mean 

4  rascal 

1  time 

3  boy 

1  meanness 

1  reverses 

2  tools 

118  burglar 

1  girl 

1  men 

1  revolver 

1  tramp 

2  burglary 

1  glove 

1  mercenary 

8  rob 

1  treasure 

2  gold 

2  merchant 

126  robber 

1  troublesome 

2  careful 

1  good 

2  minister 

10  robbery 

1  trust 

2  catch 

1  mischief 

19  rogue 

4  caught 

1  harsh 

1  misdemeanor 

1  roguish 

3  ugly 

1  caution 

18  honest 

1  mistake 

1  run 

1  undesirable 

1  chief 

4  honesty 

16  money 

2  running 

1  unjust 

1  clerk 

4  house 

5  murder 

1  unreliable 

1  clothing 

1  household 

3  murderer 

1  scare 

4  court 

1  schemer 

1  vagrant 

2  crime 

1  ignorant 

1  necessity 

1  school 

2  valuables 

15  criminal 

1  injustice 

1  neighbor 

4  scoundrel 

2  vice 

3  crook 

1  interest 

1  newspaper 

l^hot 

5  villain 

1  cry 

1  Irish 

16  nigh't 

4  silver 

1  virtue 

2  culprit 

1  none 

1  silverware 

1  cute 

11  fail 

1  noted 

1  sin 

1  want 

7  jewelry 

1  Sing  Sing 

3  watch 

2  dangerovis 

3  jewels 

1  object 

1  sinner 

1  waywardness 

4  dark 

1  judge 

1  sly 

4  wicked 

1  deceit 

1  jury 

1  pencil 

1  snake 

3  wickedness 

1  detective 

2  justice 

1  person 

7  sneak 

1  window 

1  devil 

2  pickpocket 

3  sneaking 

1  woman 

11  dishonest 

1  killed 

1  play 

1  sneaky 

1  wretched 

2  dishonesty 

1  kleptomaniac 

1  pocket 

1  spoils 

3  wrong 

596 


FREE  ASSOCIATION  TEST 


85.  LION 

4  Africa 

5  cub 

1  hearted 

27  mouse 

1  story 

1  Androclea 

2  cubs 

1  holler 

1  mule 

30  strength 

1  anger 

1  horse 

15  strong 

2  anpry 

5  danger 

1  howl 

1  N. 

1  Sultan 

32iJ  animal 

6  dangerous 

1  huge 

1  noble 

3  animab 

1  death 

1  hungry 

1  noise 

4  tame 

13  den 

3  hunter 

1  tamer 

17  bear 

3  desert 

4  hunting 

1  panther 

1  tail 

67  beast 

1  devours 

1  hyena 

2  park 

1  teeth 

1  beautiful 

1  disturber 

1  paw 

1  terrible 

1  beauty 

1  dog 

1  interested 

1  picture 

102  tiger 

2  bipr 

5  power 

2  tigers 

1  bird 

1  eat 

1  jealous 

1  powerful 

1  bite 

1  eats 

5  jungle 

1  prey 

7  ugly 

1  blood 

3  elephant 

1  jungles 

1  boisterouB 

1  enraged 

1  rage 

5  vicious 

2  bold 

16  king 

1  raging 

1  Bostock's 

3  fear 

1  revenge 

1  walks 

4  brave 

16  ferocious 

1  L. 

46  roar 

2  wicked 

I  bravery 

1  ferocity 

6  lamb 

3  roars 

12  wild 

1  Bronx 

36  fierce 

3  large 

6  roaring 

1  wildness 

1  fierceness 

10  lioness 

8  Roosevelt 

2  wildemeso 

14  cage 

6  forest 

1  lionized 

1  rough 

1  wilds 

1  camel 

1  fox 

1  lookout 

10  wolf 

6  cat 

1  fright 

1  savage 

2  woods 

1  cave 

1  frightened 

1  majestic 

1  sea 

1  wool 

1  Christian 

3  majesty 

1  shaggy 

1  wrath 

2  circus 

1  giraffe 

13  mane 

1  sharp 

2  claws 

2  great 

5  menagerie 

1  sheep 

1  yellow 

1  cow 

1  growl 

1  mice 

1  small 

1  crouching 

1  mighty 

1  stealth 

5  zoo 

2  cruel 

3  hair 

1  monkey 
86.  JOT 

1  stealthy 

1  zoology 

1  action 

2  delighted 

7  great 

1  merriment 

1  sensation 

1  amuse 

2  delightful 

18  grief 

1  merry 

1  shouting 

3  amusement 

1  despair 

7  mirth 

2  show 

1  anger 

1  hands 

1  money 

1  sing 

1  angry 

1  ecstasy 

215  happiness 

1  motherhood 

1  singing 

1  anticipation 

3  elated 

71  happy 

2  much 

2  smile 

1  arrival 

1  emotion 

1  harmony 

5  music 

1  smiling 

4  automobile 

1  engaged 

1  health 

3  song 

2  enjoyment 

1  heard 

1  news 

135  sorrow 

Iball 

3  excitement 

3  heart 

2  nice 

1  sorry 

1  bird 

2  expression 

2  heaven 

1  noise 

1  state 

1  birth 

1  extreme 

1  holiday 

1  suffering 

1  birthday 

1  exuberance 

6  home 

1  outing 

1  summer 

1  bitterness 

4  hope 

1  sunlight 

1  bless 

1  fair 

1  pain 

6  surprlSB 

1  blessing 

1  family 

1  inexpressible 

1  passing 

4  sweet 

10  bliss 

1  feel 

23  peace 

1  sweetness 

1  boy 

5  feeling 

1  joking 

1  picnic 

1  bright 

1  felt 

I  jubilant 

1  picnics 

2  time 

1  brightnehu 

1  festivity 

8  pleasant 

1  triumph 

1  buoyant 

2  fine 

1  lady 

3  pleased 

3  trouble 

1  food 

7  laugh 

121  pleasure 

1  cheer 

1  forever 

4  laughing 

1  pride 

1  unalloyed 

2  cheerful 

1  friends 

15  laughter 

1  unattainable 

8  cheerfulness 

1  fullness 

1  leap 

1  quality 

2  unhappineaa. 

2  child 

6  fun 

1  letters 

1  unhappy 

1  children 

3  life 

4  rapture 

2  Christmas 

1  gaiety 

2  light 

2  rejoice 

1  vacation 

1  comes 

1  gay 

1  like 

1  rejoicing 

H  comfort 

1  game 

2  line 

2  relief 

1  water 

1  comfortable 

1  gift 

1  lonely 

7  ride 

1  wedding 

1  company 

2  girl 

1  lots 

2  riding 

1  wetness 

1  complete 

1  girls 

6  love 

1  rider 

1  wish 

1  concert 

27  glad 

2  loving 

1  wonderful 

1  contentment 

44  gladness 

1  lovely 

1  sad 

2  work 

3  glee 

13  sadness 

1  wrath 

3  dance 

1  godliness 

1  man 

2  sailing 

S  dancing 

7  good 

2  marriage 

1  Saturday 

1  youth 

6  delight 

1  grand 

2  meeting 

1  seldom 

FREQUENCY  TABLES 


597 


87.  BE»> 

1  animal 

1  covering 

2  house 

17  pillow 

8  sleepiness 

1  aeleep 

7  pillows 

7  sleepy 

1  desired 

9  iron 

1  pleaamrc 

3  slumber 

1  baby 

1  dormitory 

1  joy 

3  post 

7  sofa 

8  bedding 

1  down 

31  soft 

4  bedstead 

1  dreamland 

2  large 

1  quilts 

5  spread 

4  blanket 

8  lay 

1  spring 

3  blankets 

1  ease 

1  laziness 

1  recline 

1  springs 

Iboat 

1  easiness 

21  lie 

1  recuperation 

1  square 

1  bowl 

2  easy 

6  lounge 

J  refreshing 
y  lepose 
1  respite 

1  stove 

8  brass 

2  low 

1  structure 

2  bug 

1  fatigue 

8  lying 

2  table 

3  feathers 

132  rest 

11  chair 

1  flannels 

1  make 

5  resting 

1  tick 

2  clean 

1  floor 

1  marriage 

1  restful 

1  time 
7  tired 
1  twilight 

1  cleanliness 

2  folding 

21  mattress 

1  robe 

12  clothes 

1  frame 

16  room 

2  clothing 

26  furniture 

1  narrow 

1  Vassar 

35  comfort 

1  negro 

1  seat 

1  comforts 

1  go 

11  night 

6  sheet 

1  want 

12  comfortable 

7  good 

7  sheets 

1  warm 

H  cot 

1  object 

1  shoes 

1  weariness 

26  couch 

2  hammock 

2  sick 

2  white 

1  counterpane 

5  hard 

1  pan 

5  sickness 

1  whiteness 

4  cover 

1  head 

3  patient 

345  sleep 

1  wide 

4  covers 

2  home 

1  peace 
88.  HBAVT 

41  sleeping 

4  wood 

1  air 

1  cloudy 

1  heart 

1  oppression 

17  stone 

1  animal 

4  coal 

2  hearted 

1  oppressive 

2  stones 

1  anvil 

1  coarse 

1  heft 

2  stout 

1  article 

1  coat 

Ihelp 

1  package 

3  stove 

1  automobile 

1  comfort 

2  horse 

1  pail 

1  strain 

1  avoirdupois 

1  cumbersome 

1  house 

1  person 
1  piano 

4  strength 
3  strong 

1  baby 

1  dark 

70  iron 

2  ponderous 

1  study 

1  bad 

1  difficult 

2  irons 

1  pound 

1  suit 

1  bat 

1  dirt 

1  pounds 

2  bed 

1  disappointment 

1  labor 

2  pressure 

6  table 

3  big 

1  discomfort 

2  laden 

8  thick 

1  body 

1  dope 

18  large 

1  quicksilver 

1  things 

, 3  books 

1  drag 

60  lead 

2  quiet 

1  thoughtful 

Z  boulders 

1  drill 

7  lift 

21  tired 

1  box 

1  drowsiness 

1  lifting 

2  rock 

2  tiresome 

1  boxes 

10  drowsy 

273  liKht 

1  rough 

4  ton 

1  boy 

3  dull 

1  lightness 

1  tough 

1  bread 

57  load 

2  safe 

3  trunk 

1  brick 

1  effort 

1  loadsome 

1  sand 

1  building 

3  elephant 

1  loud 

1  satchel 

1  uncomfortable 

1  bullet 

1  scales 

1  underwear 

4  bundle 

1  F. 

1  machine 

1  sharp 

12  burden 

1  fall 

4  man 

1  ship 

1  very 

3  burdensome 

1  feel 

1  marble 

1  short 

1  firmness 

1  mountain 

1  sickness 

1  weak 

1  cake 

1  full 

1  much 

3  sleep 

3  wearineM 

1  cannon 

1  mud 

1  sleeping 

3  weary 

1  carpet 

3  gold 

1  muscle 

1  slothful 

1  weather 

2  carry 

1  gorgeous 

1  myself 

1  slumber 

1  weigh 

1  carrying 

1  grief 

5  soft 

1  weighing 

1  cement 

2  grip 

1  no 

1  Boggy 

177  weight 

1  chair 

3  solid 

1  weighted 

1  change 

3  hammer 

1  obliging 

1  sound 

22  weighty 

X  cloth 

38  hard 

1  opposing 

1  steel 

4  wood 

%  clothes 

2  head 

2  work 

598 


FREE  ASSOCIATION  TEST 


89.  TOBACCO 


1  amber 

1  elevate 

1  Indian 

69  pipe 

7  strong 

1  anger 

1  enjoyed 

3  injurious 

3  pipes 

1  substance 

1  enjoyment 

1  intoxicate 

38  plant 

1  suffocation 

10  bad 

1  execrable 

1  plants 

2  sugar 

Ibite 

1  exhilaration 

7  juice 

3  pleasant 

2  sweet 

4  bitter 

1  evil 

2  pleasure 

1  Bob 

17  leaf 

6  poison 

1  tasty 

1  breath 

1  field 

2  leaves 

1  poor 

1  tobacco 

7  brown 

1  fields 

1  light 

2  pouch 

4  filth 

1  liquor 

I  plug 

1  unclean 

28  chew 

1  filthineas 

1  lungs 

2  unnecessary 

13  chewing 

1  filthy 

2  luxiuy 

1  refrain 

2  unpleasant 

19  cigar 

1  food 

1  ruin 

1  unwholesom? 

17  cigars 

3  maa 

2  use 

12  cigarette 

1  garden 

1  men 

1  scent 

1  used 

6  cigarettes 

5  good 

1  sensation 

1  useful 

2  comfort 

3  green 

10  narcotic 

1  sin 

2  useless 

1  curse 

1  grower 
1  growing 

2  nasty 
1  nausea 

5  smell 

387  smoke 

3  vegetable 

1  death 

18  nicotine 

98  smoking 

1  vice 

2  Virginia 

1  decay 

12  habit 

1  none 

1  smoker 

1  deviltry 

1  habits 

1  not 

15  snuff 

44  weed 

6  dirty 

1  hard 

1  nuisance 

1  solace 

1  weeds 

3  disagreeable 

3  herb 

4  spit 

1  whiff 

1  disgust 

1  herbs 

1  obnoxious 

1  stalk 

1  whiskey 

1  disgusting 

1  horrid 

3  odor 

1  stars 

1  wickedness 

3  drug 

1  horrors 

1  odorous 

2  stimulant 

1  Durham 

4  opium 
80.  BABY 

I  stimulantB 

1  yellow 

1  animal 

2  cross 

1  happiness 

1  milk 

4  sleep 

3  cries 

1  happy 

41  mother 

1  slight 

5  beautiful 

37  cry 

1  harmless 

42  small 

2  beauty 

29  crying 

1  helpless 

1  name 

1  smallest 

1  beginning 

3  cunning 

4  helplessness 

5  nice 

1  smiling 

3  being 

8  cute 

4  home 

6  noise 

3  soft 

1  bib 

1  cuteness 

3  human 

1  noisy 

2  softness 

1  big 

3  nuisance 

2  squalls 

1  birth 

4  darling 

168  infant 

7  nurse 

1  squeal 

1  blessing 

1  daughter 

1  infinitesimal 

1  squealing 

1  blue 

1  delicate 

10  innocence 

2  offspring 

1  stout 

2  body 

1  dirty 

4  innocent 

1  sunshine 

1  bonnet 

1  doll 

1  pacifier 

23  sweet 

2  bom 

6  dress 

7  joy 

1  paper 

7  sweetness 

6  bottle 

1  jump 

2  person 

1  syrup 

32  boy 

1  embryonic 

2  pink 

1  talk 
1  talks 
1  tiny 
5  trouble 
1  two 

1  bread 
1  buggy 

1  eyes 

4  kid 

1  play 
I  pleasant 

1  bundle 

1  fair 

2  family 

1  lamb 
1  laugh 

3  pleasure 
1  population 

1  cap 

5  fat 

2  laughing 

1  powder 

3  care 

1  father 

1  Lawrence 

7  pretty 

1  wagon 

28  carriage 

1  feet 

2  life 

1  walking 

2  cart 

1  female 

1  light 

4  rattle 

1  weak 

239  child 

1  flesh 

12  little 

1  rocker 

1  wealmeSs 

3  children 

1  food 

1  Lorenzo 

1  round 

1  wee 

1  childhood 

1  friend 

9  love 

2  Ruth 

1  white 

1  chubby 

1  future 

1  loveliness 

2  wife 

4  clothes 

1  lovely 

1  sex 

6  woman 

3  comfort 

26  girl 

1  sick 

22  cradle 

1  good 

2  mama 

1  sickness 

2yeU 

1  creation 

1  goodness 

4  man 

1  simple 

12  young 

1  crib 

1  growth 

1  mankind 

1  simplicity 

1  yoimgster 

1  crooning 

1  Mary 
91.  MOON 

2  sister 

4  youth 

1  astronomer 

7  body 

1  circular 

1  delicate 

Ifair 

1  astronomy 

52  bright 

3  clear 

1  deUghtful 

2  fire 

1  atmosphere 

7  brightness 

2  clouds 

1  dim 

1  flnnuiiBlit 

1  brilliant 

4  cold 

4  distance 

10  full 

2  ball 

1  coldness 

1  dreaming 

2  beam 

1  calm 

8  crescent 

6  earth 

Igirl 

1  beams 

1  change 

1  cute 

3  eclipse 

1  globe 

7  beautiful 

4  aheese 

1  equator 

1  glowtajT 

0  beauty 

1  circle 

2  dark 

6  evening 

1  grand 

FREQUENCY  TABLES 


599 


1  great 

3  lunar 

23  planet 

26  shine 

1  steamer 

1  guard 

1  planets 

4  shines 

1  stone 

8  man 

1  pleasant 

12  shining 

2  struck 

3  half 

3  moonlight 

12  shiny 

120  sun 

2  heaven 

1  mountain 

1  quiet 

4  silver 

1  sweet 

3  heavens 

1  mystery 

6  silvery 

4  high 

1  reflection 

1  size 

1  turkey 

1  illuTnination 

1  necessary 

1  rise 

73  sky 

3  new 

1  rises 

1  solar 

1  valuable 

1  lady 

66  night 

1  rising 

1  sound 

Hake 

33  round 

1  splendid 

1  wan 

9  large 

1  object 

2  spoon 

2  water 

281  light 

1  ocean 

4  satellite 

1  spooning 

3  white 

3  love 

1  one 

2  sea 

32  star 

1  wish 

1  lovelineBs 

1  orbit 

1  see 

93  stars 

2  lovely 

2  pale 

1  seeing 

1  sentimental 

92.    SCISSORS 

1  starlight 

11  yellow 

1  apart 

3  dressmaking 

1  instruments 

1  nippers 

1  skirt 

4  article 

5  dull 

66  knife 

6  paper 

1  spool 
23  steel 

2  barber 
1  blade 
1  blades 

1  edge 

1  fate 

1  firecrackers 

6  knives 

1  lever 
1  ILneu 

1  point 
1  pointed 

1  razor 

1  string 

2  tailor 

3  thimble 

4  thread 

1  blunt 

1  flowers 

1  lost 

1  niching 

35  cloth 

2  garments 

2  machine 

1  Sarah 

1  tongs 

1  clothing 

1  glistening 

1  material 

1  screw 

10  tool 

1  cord 

6  goods 

1  metal 

1  severing 

1  tools 

1  crooked 

1  grating 

1  millinery 

2  sew 

1  trousers 

2  crossed 

7  grind 

1  mother 

10  sewing 

1  useful 

347  cut 

190  sharp 

1  usefulness 

114  cutting 

1  handle 

1  nails 

5  shaiTDness 

1  utensil 

1  cutlery 

1  handy 

1  necessity 

1  sharpen 

4  needle 

40  shears 

1  weapon 

1  dress 

6  implement 

4  needles 

2  shut 

1  woman 

2  dressmaker 

36  instrument 

1  nickle 
93.  Q,tJIBT 

1  silver 

2  work 

1  action 

3  demure 

2  life 

3  pleasure 

3  solemn 

2  alone 

1  disposition 

1  like 

2  solitude 

1  always 

1  docile 

1  loneliness 

.1  quick 

3  soothing 

1  asleep 

1  dreary 

3  lonely 

2  quite 

4  sound 

IduU 

2  lonesome 

2  soundless 

2  baby 

1  dumb 

1  looks 

1  rabbits 

1  speechless 

1  beautiful 

1  lovely 

1  refined 

1  state 

1  beauty 

8«ase 

48  loud 

1  relief 

2  steady 

1  bed 

1  easiness 

1  low 

6  repose 

136  still 

2  behave 

49  easy 

1  reserved 

16  stillness 

3  boisterous 

5  evening 

1  man 

68  rest 

2  study 

1  bore 

1  melancholy 

4  resting 

1  stupid 

1  boy 

1  family 

1  mind 

19  restful 

1  subdued 

1  breeze 

1  feeling 

1  Miss  K. 

2  restless 

1  summer 

1  brook 

1  moon 

6  room 

1  Sunday 

1  butterfly 

1  genteel 
3  gentle 

1  mountains 
1  music 

1  rough 

2  sweet 

20  calm 

1  gentleman 

1  myself 

1  sad 

2  talk 

1  cattle 

2  girl 

1  sea 

1  time 

6  child 

7  good 

1  nature 

1  serene 

1  times 

1  children 

1  green 

2  nice 

1  sheep 

1  timid 

4  church 

38  night 

1  sickness 

1  tomb 

1  color 

1.  happy 

50  noise 

13  silence 

1  tranquil 

2  comfort 

2  })8rmle8a 

16  noiseless 

15  silent 

1  tree 

T  comfortable 

1  harsh 

1  noisiness 

24  sleep 

1  twilight 

1  composed 

1  heaven 

113  noisy 

3  sleeping 

2  contented 

6  home 

1  nook 

1  sleepy 

1  village 

21  country 

1  hour 

8  slow 

1  violent 

1  Creal 

S  house 

1  park 

1  slowness 

1  voice 

1  cricket 

at  hospital 

26  peace 

1  slumber 

8  cross 

1  humble 

2  peaceable 

1  slumbers 

1  walk 

52  peaceful 

1  smart 

1  water 

8  dark 

IJoy 

4  peacefulness 

1  smooth 

1  well 

1  darkness 

2  people 

1  sober 

1  WUton 

8  day 

1  landscape 

1  person 

10  soft 

1  wish 

2  death 

1  laughing 

4  place 

1  softly 

1  wood 

1  degree 

1  library 

4  pleasant 

1  softness 

10  woods 

600 


FREE  ASSOCIATION  TEST 


94.    GRSCN 

8  apple 

1  definite 

1  grew 

1  ocean 

1  sky 

6  dress 

1  grief 

1  olive 

1  slow 

2  beautiful 
1  bird 

2  earth 

1  ground 

2  orange 

1  small 

1  soft 

13  black 

3  envy 

1  hat 

3  paint 

2  sour 

1  bloomy 

1  Erin 

1  hill 

2  jjaper 

1  spinach 

2  blotter 

4  eyes 

2  horn 

1  peaceful 

9  spring 

46  blue 

1  farmer 

1  horrid 

2  peas 

1  stain 

1  book 
5  bright 
8  brown 
1  butterfly 

1  cabbage 
1  calm 

1  favorite 
12  field 

10  fields 

3  flag 

4  flower 

2  flowers 

1  hue 

6  Ireland 
14  Irish 

1  jealousy 

11  pink 
6  plant 

1  plants 

2  pleasant 

1  pleasing 
4  pretty 

6  purple 

2  quiet 

1  summer 

1  tea 
10  tree 
29  trees 

1  unripe 

1  carpet 
1  cheese 
3  cloth 

2  foliage 

1  food 

1  foolishness 

1  landscaptj 
1  laurel 

1  vegetable 
1  vegetables 

200  color 

1  forest 

5  lawn 

42  red 

3  verdant 

1  colors 

3  fresh 

8  leaf 

6  restful 

1  verdure 

1  comfort 

1  fruit 

13  leaves 

2  ribbon 

1  com 

4  Ught 

2  ripe 

1  warning 

1  country 

1  covetous 

2  cucumber 
1  curtain 

1  gay 

1  glasses 

1  meadow 

2  sea 

1  wearing 
31  white 

1  gold 

1  meadows 

4  shade 

1  wood 

1  grand 

2  mountain 

2  shamrock 

2  woods 

1  grapes 

1  shutters 

8  dark 

284  grass 

1  name 

1  sight 

54  yellow 

1  Dartmouth 

5  gray 

4  nature 
95.   SAL,T 

1  Bilk 

1  young 

1  acrid 

1  dish 

1  Lake 

2  potato 

18  sour 

3  air 

1  drink 

1  life 

4  potatoes 

5  spice 

1  apple 

2  dry 

1  lot 

1  powder 

1  spill 

2  apples 

1  preparation 

1  stickiness 

1  article 

5  earth 

4  mackerel 

2  preservation 

88  sugar 

17  eat 

1  marsh 

1  preservatives 

1  sustenance 

1  barrel 

7  eatable 

18  meat 

1  preserving 

27  sweet 

1  barren 

8  eating 

1  meats 

1  quotation 

1  Syracuse 

1  bath 

2  eggs 

1  medicinal 

1  beef 

1  epileptics 

1  melt 

1  refreshing 

14  table 

40  bitter 

2  mine 

4  relish 

2  tart 

1  bowl 

1  finish 

3  mines 

7  rock 

87  taste 

1  box 

4  fish 

37  mineral 

1  rocks 

1  tasting 

2  bread 

21  flavor 

1  mustard 

2  tasteful 

2  brine 

3  flavoring 

1  saline 

6  tasty 

1  bromide 

46  food 

1  NaCT 

1  saltpetre 

1  tasteless 

7  butter 

1  France 

5  necessary 

3  salty 

1  temper 

11  fresh 

3  necessity 

1  sandwiches 

4  thirst 

2  celery 

1  needed 

1  Saratoga 

2  thirsty 

9  cellar 

1  glass 

1  needful 

1  saving 

1  trees 

2  chemical 

9  good 

1  nice 

10  savor 

7  use 
2  useful 
1  uses 
1  using 

1  codfish 

2  condiment 

1  halite 

36  ocean 

1  savory 
18  sea 

1  cook 

1  ham 

12  season 

2  cooking 

4  hard 

1  pantry 

31  seasoning 

1  cows 

1  horrid 

1  paper 

2  shake 

5  vegetable 

1  cream 

1  pasture 

4  shaker 

1  vegetables 

1  ice-cream 

142  pepper 

8  sharp 

1  victuals 

1  deposit 

1  ingredient 

1  petre 

1  sheep 

1  vinegar 

1  digestible 

1  phvsic 

1  smart 

3  dinner 

1  Kenilworth 

1  pickles 

1  snapping 

34  water 

1  dirt 

1  kitchen 

5  pork 

1  sodium 

2  wet 

1  disagreeable 

1  potassium 
96.    STREET 

2  soup 

36  white 

1  air 

3  boulevard 

1  byway 

1  confusion 

1  Devon 

18  alley 

1  Bowery 

1  congestion 

1  direct 

6  asphalt 

2  boy 

10  car 

2  corner 

1  directions 

1  automobiles 

1  brick 

iS  cars 

1  country 

4  dirt 

63  avenue 

2  broad 

1 'carriage 

2  crooked 

5  dirty 

1  avenues 

6  Broadway 

82  city 

1  cross 

1  distance 

1  Brooklyn 

1  Clarkson 

3  crowd 

1  drive 

1  better 

1  buildini; 

7  clean 

1  crowded 

1  driving 

1  bitter 

1  business 

1  cleaner 

2  driveway 

12  block 

4  busy 

1  colors 

1  dark 

1  dry 

FREQUENCY  TABLES 


601 


4  dust 

5  dusty 

1  dwellings 

1  earth 

1  Eighty-sixth 

1  Eleventh 

1  Elm 

I  even 

1  fertile 
1  Fifteenth 

1  fine 

2  flaffs 

1  Forty-third 

1  garden 
1  going 

1  gravel 

2  gutter 

1  hard 
1  lieat 
1  Hester 
7  highway 
1  home 


1  Albert 
1  all 

3  Alphonso 
1  antiquity 
1  Arthur 

4  authority 

Ibad 
1  boss 

1  card 

1  cards 

2  chess 
1  chief 

3  command 

1  commanding 
9  commander 

2  conqueror 
J3  country 

1  court 

1  courtier 
63  drown 

2  crowned 

1  daughter 
1  diamonds 
1  dignity 
1  dislike 


2  American 

1  bacteria 

2  bad 
2  beer 

1  biscuit 
6  bitter 

2  box 
66  bread 

1  brick 
136  butter 

2  buttermilk 

8  cake' 

2  Camembert 
1  casein 
1  chalk 
1  cheesecloth 
1  chum 
4  cloth 
1  cold 
4  color 


2  horses 
1  hot 

11  house 
21  houses 
1  hustle 

3  land 
21  lane 

1  large 
1  length 
1  level 

1  light 

2  live 

2  location 
1  lonely 
29  long 

5  Main 
1  Market 
1  Maxflield 
1  motion 
1  mud 

1  musician 

2  name 
21  narrow 

3  New  York 


1  dog 
1  duke 

30  Edward 
11  emperor 

3  empire 
20  England 

1  ermine 

1  family 
1  farce 
1  first 
1  fool 
1  foreign 
1  friend 

1  garment 

2  George 
1  glory 

1  good 

1  govern 

4  government 
6  governor 

2  great 

1  greatness 

1  Hamlet 
1  happy 


1  corn 

9  cow 

3  cows 

1  cracker 
SO  crackers 
SO  cream 

1  creamery 

1  crust 
9  curd 

3  curds 

2  cut 

1  cutter 

i  dairy 

2  delicatessen 

1  derby 

2  diet 

1  digestible 

1  digestion 

2  dinner 
1  dish 

4  dislike 


1  nice 
8  noise 

5  noisy 
12  number 

1  numbers 

1  One-flfteenth 
1  One-sixteenth 
1  opening 

11  passage    . 

1  passageway 

2  passway 

12  path 

2  jiathway 
1  pave 

13  paved 

25  pavement 
1  paving 
1  pebble 

1  Pecan 
22  people 
16  place 

2  pleasant 

1  pleasure 

2  pretty 

97.  KING 

8  head 

1  helmet 

2  Henry 
2  high 

1  Holland 
1  honorable 
1  horrible 

1  imperial 
1  inheritance 
1  Italy 

1  John 

1  judgment 

2  Kaiser 
1  king 

6  kingdom 

1  large 

1  law 

2  leader 
1  lion 

1  lord 

1  Louis  XVI. 

1  loyal 

1  majestic 

98.  che:s:se: 

1  Dutch 

1  eagle 
67  eat 
29  eating 

1  eaten 
19  eatable 

3  eatables 

1  edible 

2  eggs 


1  factory 

2  fat 

1  feast 
1  fine 

1  fondness 
91  food 

2  fresh 

1  fromage 
Brie 


de 


15  good. 


1  racket 

1  residence 
91  road 

4  roads 

2  roadway 

1  see 

1  shopping 

3  short 

26  sidewalk 

2  sidewalks 

1  Sixty-seventh 

2  Sixty-third 
2  smooth 

1  space 

4  square 
8  stone 
8  stones 

17  straight 
1  sun 
1  sweep 

1  tenements 
1  terrace 
23  thoroughfare 


8  majesty 

2  male 
43  man 

3  master 
1  mean 

1  Midas 
49  monarch 

4  monarchy 

1  nation 

1  nobility 

3  noble 

2  nobleman 
1  none 

1  officer 

1  old 

2  palace 
6  person 

1  picture 

2  pompous 
18  power 

4  powerful 
4  president 
1  princess 
1  Prussia 


5  green 
1  grocer 
1  grocery 

1  ham 

2  hard 
1  head 

1  heap 

2  hole 
2  holes 
2  holey 
1  hoops 
1  hunger 
1  hungry 

1  Indigestion 

ll'am 

1  kind 
4  knife 

13  Limburgen 


26  towh 
1  tracks 
7  traffic 
3  travel 
1  tree 

1  trees 

2  trolley 
1  turmoil 


1  vehicles 

9  village 

3  wagon 

2  wagons 

78  walk 

23  walking 

2  walks 

1  Wall 

1  Washington 

14  way 

1  wet 

1  white 

35  wide 

1  width 

1  WoodhuU 

354  queen 

1  regal 
1  regent 
8  reign 
1  rich 

1  Richard 

2  royAl 

5  rovalty 
10  nile 
4  rules 
162  ruler 

1  Saxony 

2  sceptre 
1  slave 

1  somebody 
8  sovereign 
1  Spain 

1  stories 

2  subject 
1  supreme 

21  throne 
1  title 
1  town 
1  tyrant 


1  lump 

2  lunch 

1  macaroni 

1  maggot 

2  maggots 
1  meat 

25  mice 
1  microbes 
1  mild 
106  milk 
1  milky 

1  mixture 

2  moon 
1-  mould 

1  mouldy 
13  mouse 

2  mustard 

1  nice 

1  nourishment 

1  nutrition 


602 


FREE  ASSOCIATION  TEST 


9  odor 

4  rarebit 

1  salt 

2  solid 

1  tasty 

1  odorous 

8  rat 

8  sandwich 

5  sour 

1  thin 

7  rats 

2  sandwiches 

1  strengthening 

1  pickles 

1  red 

1  sauce 

12  strong 

5  vegetable 

6  pie 

1  resentment 

1  scent 

1  sugar 

1  vegetables 

1  plain 

1  rich 

2  Switzer 

5  supper 

1  plate 

4  Roquefort 

8  sharp 

2  sweet 

1  wafers 

1  poor 

1  rough 

1  skippers 

16  Swiss 

3  white 

1  poultry 

2  round 

33  smell 

1  Switzerland 

1  worms 

1  price 

1  smells 

2  product 

1  sage 

7  soft 
99.    BLOSSOM 

8  taste 

32  yellow 

60  apple 

1  clover 

39  fruit 

2  odor 

1  seeds 

4  apples 

5  color 

2  orange 

1  shrubberies 

1  art 

1  colors 

2  garden 

2  orchard 

1  small 

1  country 

Igin 

2  smell 

10  beautiful 

1  dainty 

2  daisy 

1  delicate 

1  girl 

1  pansies 

1  soft 

9  beauty 

1  green 

1  pansy 

23  spring 

1  beRinning 

2  grow 

1  peacefulness 

1  sprout 

1  berries 

2  growth 

4  peach 

1  stem 

28  bloom 

1  petal 

4  summer 

7  blooming 

1  eat 

1  handsome 

1  petals 

1  sun 

1  blow 

1  happiness 

1  picking 

15  sweet 

1  bonk 

2  fair 
1  falling 

1  hepatica 

7  pink 

4  brierht 

13  plant 

1  T. 

23  bud 

1  falls 

3  leaf 

1  pleasure 

40  tree 

3  buds 

3  field 

1  leaves 

1  plum 

17  trees 

1  bursting 

1  fields 
467  flower 
73  flowers 

2  lilacs 

1  pour 

1  vine 

1  bush 

2  bushes 

llily 

15  pretty 

3  violet 

1  buttercups 

1  foliage 

2  forth 

6  fragrance 

1  magnificent 

3  red 

1  weeds 

5  cherries 

2  May 
1  mimosa 

17  rose 
4  roses 

8  white 

4  cherry 

4  fragrant 

2  yellow 

1  clematis 

1  frail 

1  nice 
100.    AFRAID 

1  scent 

1  youth 

1  accidents 

5  cowardice 

2  ghosts 

4  nervousness 

1  soldier 

1  action 

3  cowardly 

1  girl 

3  never 

1  somebody 

2  alarm 

1  crowd 

4  go 

12  night 

1  sore 

2  always 

1  crying 

1  goblins 

3  no 

2  sorrow 

3  anerer 

1  God 

1  nobody 

1  sorry 

2  anCTy 

15  danger 

1  guilty 

2  noise 

1  spirit 

2  animal 

2  dangerous 

1  noisy 

1  spiritual 

2  animals 

1  dare 

1  happy 

1  not 

1  startled 

1  anxiety 

114  dark 

2  harm 

5  nothing 

1  startling 

2  automobile 

16  darkness 

1  heart 

1  stav 

1  awful 

2  death 

1  heroism 

1  obsession 

1  stillness 

1  backwardness 

2  bad 

2  bashful 
1  battle 
1  bears 

1  blow 

2  bold 
1  boy 

18  brave 
1  bravery 

1  brother 

3  burprlar 

2  burglars 

1  careful 

1  deep 

1  hide 

1  opposition 

1  strong 

1  depressed 

1  home 

1  suddenness 

1  desire 

1  hope 

1  palpitation 

1  suffering 

1  dislike 

1  horse 

1  patient 

1  sure 

1  do 

1  hurt 

1  patients 

1  dog 

1  plucky 

1  tempted 

1  dogs 

1  insect 

1  police 

1  terrified 

1  don't 
1  doubt 
7  dread 

Ijoy 
1  joyful 

1  quiet 
1  rat 

9  terror 
3  thief 
1  thought 

1  dreading 
1  dreadful 

1  dream 

2  emotion 

1  licked 
1  lightning 
3  lion 

1  loneliness 
3  lonely 

1  rats 
1  retreat 

1  riot 

2  robbers 
1  rocks 

1  threaten 

1  thunder 
55  timid 

2  timidity 
1  timorous 

2  cat 

2  faith 

6  lonesome 

4  run 

1  to-night 

1  cheerfulness 

197  fear 

1  loss 

1  running 

2  tremble 

8  child 

8  fearful 

1  trouble 

1  children 

8  fearless 

3  man 

1  scare 

1  trust 

1  cold 

2  feeling 

1  manner 

106  scared 

1  unable 

1  comfort 

1  fierce 

1  memory 

1  scary 

1  uncertain 

1  comforted 

1  forward 

1  mild 

1  scream 

5  uneasy 

1  unhappiness 

1  unknown 

1  company 

9  fright 

1  Miss  K. 

1  sensitive 

1  confidence 

2  frighten 

1  mice 

i  shiver 

1  conscience 

48  frightened 

2  mouse 

2  shrinking 

1  unprotected 

11  courage 

1  frightful 

1  shudder 

6  courageous 

1  frog 

1  need 

2  shy 

1  woman 

1  cow 

2  nerve 

1  sickness 

1  women 

1  cows 

1  gallant 

1  nerves 

1  sleep 

1  worried 

et  orwwrd 

4  ghost 

65  nervous 

3  wony 

APPENDIX  TO  THE  FREQUENCY  TABLES 


General  Rules 

1.  Any  word  combination  which  is  to  be  found  in  the 
frequency  tables,  but  only  in  the  reverse  order  from  that  in 
which  it  occurs  in  a  test  record  under  consideration,  is  to  be 
classed  as  a  normal  reaction. 

2.  Any  reaction  word  which  is  a  synonym  or  an  an- 
tonym of  the  corresponding  stimulus  word  is  to  be  classed 
as  normal. 

1.  TABLE 

Any  food  or  meal. 

Any  room  or  apartment. 

Any  article  of  table  linen,  china,  silver,  or  furnishings. 

Word  designating  any  special  variety  of  tables. 

Any  word  pertaining  to  appetite. 

2.  DAKK 

Any  source  of  illumination. 

Any  enclosure  from  which  light  is  wholly  or  in  a  large  measure  excluded. 

Word  referring  to  physiological  pigmentation  of  tissues  exposed  to  view. 

Any  division  of  the  diurnal  cycle. 

Any  color  or  coloring  material. 

Anything  which  obscures  Hght. 

3.      MUSIC 

Any  musical  instrument. 
Name  of  any  composer  or  musician. 
Special  or  general  name  of  any  musical  composition. 
Term  designating  rhythm,  tempo,  loudness,  or  pitch. 
Name  of  any  dance. 

Term  expressing  subjective  effect  of  music. 

603 


604  FREE  ASSOCIATION  TEST 

4.      SICKNESS 

Term   designating   any    disease,    symptom,    injury,    or   physiological 

function. 
Any  cause  of  disease. 

Any  means  or  measure  of  treatment  of  disease. 
Any  anatomical  organ  or  region. 
Word  denoting  mode  of  termination,  results,  consequences,  or  indirect 

effects  of  disease. 
Any  term  of  prognostic  import. 
Common  or  proper  name  of  any  person. 

5.  MAN 

Word  denoting  or  implying  age  of  a  person. 

Any  of  the  well-known  male  sexual  characteristics. 

Occupation  or  profession  more  or  less  peculiarly  masculine. 

Word  pertaining  to  familial  relationships  or  domestic  organization. 

Word    pertaining    to    sexual    relationships;  any    word    denoting    the 

opposite  sex. 
The  proper  name  of  any  male  person. 
Any  article  of  male  apparel. 

6.  DEEP 

Any  vessel  or  contamef . 
Any  natural  or  artificial  body  of  water. 
Any  depression  of  surface. 

Any  object  natm-aUy  situated  or  often  artificially  placed  at  a  compara- 
tively great  distance  below  the  surface. 
Any  act  of  progress  from  surface  to  depth. 

7.  SOFT 

Any  article  of  food. 
Any  fabric. 

8.     EATING 

Any  article  of  table  linen,  china,  or  sUver. 

Any  organ  of  digestion;  any  function  of  nutrition. 

Any  article  of  food;  any  meal. 

Any  private  or  public  eating  place. 

Word  denoting  taste. 

9.      MOUNTAIN 

Name  of  any  mountain,  mountain  range,  or  mountainous  country. 
Word  pertaining  to  shape,  geological   composition,   fauna,   or  flora   of 

mountains  or  mountainous  regions. 
Any  term  of  physical  geography. 


APPENDIX  TO  THE  FREQUENCY  TABLES  605 

10.  HOUSE 

Any  place  of  house  location. 

Any  part  of  a  house. 

Any  material  used  in  the  construction  of  a  house. 

Any  part  of  the  process  of  construction  of  a  house. 

Laborer  or  mechanic  having  to  do  with  the  construction  of  a  house. 

Any  commercial  term  pertaining  to  ownership,  taxes,  mortgages,  sale, 

renting,  or  occupancy  of  a  house. 
Any  article  of  furniture. 

11,  BLACK 

Any  object  or  substance  that  is  always  or  often  black  or  dark  in  color. 

Any  color. 

Word  denoting  limitation  or  obscuration  of  light. 

Any  word  clearly  related  to  the  word  Black  used  as  a  proper  name. 

12.      MUTTON 

Any  article  of  food;  any  meal. 

Any  animal,  or  class  or  group  of  animals,  whose  meat  is  used  for  human 

consumption  as  food. 
Any  article  of  table  linen,  china,  silver;  any  cooking  utensil. 
Word  designating  any  person  engaged  in  the  preparation  of  meats  for 

consumption. 
Word  denoting  any  process  employed  in  the  preparation  of  meats  for 

consumption. 

13.      COMFORT 

Any  agreeable  or  disagreeable  subjective  state. 

Any  object,  act,  or  condition  that  contributes  to  comfort  or  produces 
discomfort. 

14.      HAND 

Any  simple  function  of  the  hand;  work  requiring  special  manipulation. 
Word  denoting  skill  or  any  degree  of  skiU. 
Any  part  or  any  tissue  of  the  body. 

15.      SHORT 

Any  word  involving  the  concept  of  duration. 

Common  or  proper  name  of  any  person. 

Any  word  denoting  shape,  relative  or  absolute  dimension,  or  distance. 

Any  object  in  which  characteristically  one  dimension  exceeds  any  other. 


606  FREE  ASSOCIATION  TEST 


16.     FRUIT 


Any  article  of  food;  any  meal. 

Any  process  employed  in  the  cultivation  of  fruits  or  in  their  preparation 

for  consumption. 
Word  designating  any  person  engaged  in  the  cultivation  of  fruits  or  in 

their  preparation  for  consumption. 
Any  article  of  table  linen,  china,  or  silver. 

17.     BUTTEBFLT 

Any  bird,  worm,  or  insect. 
Any  flower. 
Any  color. 

18.     SMOOTH 

Any  object  possessing  a  smooth  surface  as  a  characteriatic  feature. 
Any  fabric. 

19.      COMMAND 

Word  denoting  any  means  of  influence  of  one  mind  upon  another 

intended  to  produce  acquiescence. 
Word  denoting  or  implying  acquiescence  or  lack  of  it. 
Term  applied  to  any  commanding  oflficer  or  to  any  person  in  authority. 


Any  article  of  furniture. 
Any  room  or  apartment. 


20.     CHAIB 


31.     SWEET 


Any  substance  having  a  sweet  taste.  , 

Common  or  proper  name  of  a  child  or  woman.  ^ 

S3.     WHISTLE 

Any  instrument  or  any  animal  producing  a  shrill  musical  sound. 

33.     WOMAN 

Word  denoting  or  implying  age  of  a  person. 

Any  of  the  well-known  female  sexual  characteristics. 

Occupation  or  profession  more  or  less  peculiarly  feminine. 

Word  pertaining  to  familial  relationships  or  domestic  organization.  ~ 

Word   pertaining   to    sexual   relationships;  any   word   denoting   the 

opposite  sex. 
Name  of  any  female  person. 
Any  article  of  female  apparel. 


APPENDIX  TO  THE  FREQUENCY  TABLES  607 

24.  COLD 

Name  of  any  location  characterized  by  low  temperature. 

Any  illness  or  symptom  which  may  be  caused  by  exposure  to  cold. 

Any  division  of  the  annual  cycle. 

Any  food  that  is  always  or  often  served  cold. 

Any  means  or  measure  of  protection  against  cold. 

Any  state  of  the  natural  elements  causing  a  sensation  of  cold. 

Word  denoting  subjective  characterization  of  or  reaction  to  cold. 

25.  SLOW 

Any  means  or  manner  of  locomotion. 

Any  word  involving  the  concept  of  rate  of  progress  with  reference  either 

to  time  or  to  intensity  of  action. 
Common  or  proper  name  of  any  person. 

26.  WISH 

Word  implying  fulfillment  of  a  wish  either  by  achievement  or  through 

acquiescence. 
Word  implying  non-fulfiUment  of  a  wish. 
Word  denoting  any  state  of  longing  or  anticipation. 
Word  denoting  any  state  free  from  longing  or  anticipation. 
Word  denoting  a  prayer  or  request. 
Word  denoting  a  state  of  happiness. 

27.  ICITEB 

Any  body  of  water. 

Any  part  of  a  river. 

Any  plant  or  animal  living  in  rivers. 

Any  term  of  physical  geography. 

Any  vessel  or  contrivance  for  navigation. 

28.     WHITE 

Any  object  or  substance  that  is  always  or  often  white  or  very  light  in 

color. 
Any  color. 
Any  word  clearly  related  to  the  word  White  used  as  a  proper  name. 

29.     BEAUTIFUL 

Any  word  denoting  aesthetic  pleasure. 

Name  of  any  female  person. 

Any  product  of  the  fine  arts  or  of  decorative  handicraft. 

Any  decorative  plant  or  flower. 

Any  article  of  attire. 


608  FREE  ASSOCIATION  TEST 

Natural  scenery. 

Any  division  of  the  diurnal  cycle. 

30.     WINDOW 

Any  word  pertaining  to  illumination. 

Word  pertaining  to  movements  of  air. 

Any  attachment  to  a  window  for  the  control  of  transmission  of  light  or 

air. 
Any  building  or  apartment. 

31.     HOUGH 

Any  object  or  substance  which  is  characteristically  rough  to  the  touch. 

Word  denoting  or  implying  irregularity  of  surface. 

Any  skin  lesion  which  may  impart  to  the  skin  the  quahty  of  roughness. 

Any  .word  implying  carelessness,  lack  of  consideration,  or  crudeness; 
any  word  used  to  designate  action  or  conduct  which  may  be  char- 
acterized as  careless,  inconsiderate,  or  crude. 

33.      CITIZEN 

Any  word  pertaining  to  political  organization,  or  to  factors. either  favor- 
able or  unfavorable  to  it. 
Any  term  or  proper  name  of  political  geography. 
Common  or  proper  name  of  any  male  person. 

33.     FOOT 

Any  means  or  manner  of  locomotion  involving  the  use  of  the  feet. 

Any  part  or  any  tissue  of  the  animal  body. 

Any  article  of  foot-wear. 

Any  way  constructed  or  used  for  walking. 

Any  unit  of  linear  measure. 

34.  SPIDER 

Word  employed  to  designate  subjective  characterization  of  or  reaction 

to  an  object  of  dislike. 
Any  insect. 
Word  pertaining  to  the  characteristic  habits  of  spiders,  with  reference 

either  to  location  and  construction  of  nest,  or  to  maimer  of  catching 

prey. 

35.  NEEDLE 

Any  material  used  in  making  clothes. 

Any  special  sewing  operation;  any  occupation  in  which  sewdng  con- 
stitutes part  of  the  work. 


APPENDIX  TO  THE  FREQUENCY  TABLES  609 

Any  special  kind  of  needles. 

Any  instrument  which  is  used  in  connection  with  a  needle  in  any  opera- 
tion, or  of  which  a  needle  forms  a  part. 

36.     RED 

Word  which  may  be  used  to  express  subjective  characterization  of  the 

red  color. 
Any  object  or  substance  which  is  always  or  often  red  in  color. 
Anything  which  is  by  convention  or  common  usage  connected  with  the 

red  color. 
Any  organ,  tissue,  or  lesion,  exposed  to  view,  which  may  have  a  red  color 

imparted  to  it  by  the  blood  or  by  physiological  pigment. 
Any  color  or  coloring  material. 
Any  word  implying  light  through  incandescence. 

37.  SLEEP 

Word  denoting  somnolence  or  a  state  of  lowered  consciousness;  anything 
which  is  a  cause  of  somnolence  or  of  lowered  consciousness;  any- 
thing which  induces  a  desire  to  sleep. 

Word  denoting  a  state  of  active  consciousness  or  a  transition  from 
lowered  to  more  active  consciousness. 

Any  division  of  the  diurnal  cycle. 

Any  word  more  or  less  commonly  used  to  characterize  sleep  in  any  way. 

Any  article  of  bedding,  bed-linen,  or  night-clothes. 

Any  article  of  furniture  used  for  sitting  or  lying. 

38.  ANGER 

Any  affective  state;  any  common  demonstration  of  emotion. 
Any  common  cause  or  provocation  of  anger. 

Action  or  conduct  caused  by  anger;  word  used  to  characterize  such 
action  or  conduct. 

39.      CARPET 

Any  material  of  which  carpets  are  made. 

Any  article  of  house  furniture,  hangings,  or  decorations. 

Word  denoting  home,  house,  or  any  part  of  a  house. 

Word  pertaining  to  the  manufacture  or  care  of  carpets,  or  denoting  a 

person  engaged  in  the  manufacture,  sale,  or  care  of  carpets. 
Any  country  especially  noted  for  the  manufacture  of  carpets  or  rugs. 
Any  color. 

40.      GIRL, 

Word  denoting  or  implying  age  of  a  person. 

Any  of  the  weU-known  female  sexual  characteristics. 


610  FREE  ASSOCIATION  TEST 

Occupation  or  profession  more  or  less  peculiarly  feminine. 
Word  pertaining  to  familial  relationships  or  domestic  organization. 
Word  pertaining  to  sexual  relationships;  any  word  denoting  the  oppo- 
site sex. 
Name  of  any  female  person. 
Any  part  of  a  person's  body. 
Any  article  of  female  apparel. 

41.     HIGH 

Any  word  denoting  or  implying  skill,  training,  achievement,  or  position. 

Any  word  denoting  or  implying  valuation. 

Any  architectural  structure. 

Any  object  of  which  the  vertical  dimension  characteristically  exceeds 

any  other. 
Any  act  of  progress  from  a  lower  to  a  higher  level. 
Name  of  any  mountain  or  mountain  range. 
Anything  characteristically  situated  at  a  high  level. 
Anything  characteristically  variable  in  height. 

43.     WORKING 

Any  occupation,  profession,  art,  or  labor. 

Direct  results  or  consequences  of  work. 

Any  place  of  employment. 

Rest,  recreation,  inaction,  or  disinclination  to  work. 

Word  denoting  energy,  material,  capital,  equipment. 

43.      SOUR 

Any  substance  or  object  which  is  always  or  often  sour  in  taste. 
Any  word  denoting  a  taste  or  flavor  quality. 

44.     EARTH 

Any  substance  which  enters  into  the  composition  of  soil. 

Word  pertaining  to  the  utilization  or  cultivation  of  natural  resources; 

any  product  of  agriculture. 
Any  term  of  physical  geography,  geology,  mineralogy,  meteorology,  or 

astronomy. 

45.     TROUBLE 

Any  affective  state. 

Any  general  cause  of  active  emotional  states. 

Any  common  manifestation  of  emotion. 

Word  denoting  or  implying  defeat. 

Word  denoting  or  implying  caution  or  lack  of  it. 

Any  task. 


APPENDIX  TO  THE  FREQUENCY  TABLES  611 

46.      SOLDIER 

Word  pertaining  to  military  organization. 

Word  pertaining  to  any  military  operation. 

Word  pertaining  to  military  discipline  or  to  military  decoration. 

Any  article  of  military  or  naval  equipment  or  attire. 

Common  or  proper  name  of  any  male  person. 

Name  of  any  country. 

Word  pertaining  to  political  organization. 


47.      CABBAGE 

Any  article  of  food;  any  meal. 

Any  article  of  table  linen,  china,  silver;  any  cooking  utensil. 
Any  process  of  cooking. 

Word  used  to  designate  any  person  engaged  in  the  cultivation  of  cab- 
bages or  in  their  preparation  for  consumption. 

48.     HARD 

Any  solid  article  of  food. 
Word  denoting  or  implying  impact. 
Any  task  or  labor. 

Any  substance  which  is  hard  or  unyielding. 

Any  agency  or  process  by  which  a  substance  is  solidified  or  hardened. 
Any  article  of  furniture  used  for  sitting  or  lying. 

Any  trait  of  disposition  characterized  by  lack  of  readiness  to  yield  or 
lack  of  consideration  for  others. 

49.     EAGLE 

Any  bird. 

Any  piece  of  currency. 

Anything  in  connection  with  which  the  word  eagle  is  used  in  a  symbolic 

sense. 

50.      STOMACH 

Any  anatomical  organ  or  region. 

Any  article  of  food;  any  meal. 

Word  pertaining  to  ingestion  and  assimilation  of  food. 

Term  denoting  health  or  disease;  any  medicament. 

51.      STEM 

4ny  object  which  has  a  stem. 

Any  part  of  a  plant. 

Any  object  which  is  long,  slender,  and  more  or  less  rigid. 


612  FREE  ASSOCIATION  TEST 

53.      LAMP 

Any  means  or  source  of  illumination. 
Word  denoting  or  implying  illumination. 

53.      DREAM 

Any  product  of  imagination. 

Any  psychical  phenomenon;  any  part  of  the  psychical  organ. 

Word  denoting  or  implying  unreality  or  uselessness. 

Word  denoting  or  implying  mystery  or  occultism. 

Any  division  of  the  diurnal  cycle. 

Any  article  of  bedding,  bed-linen  or  night-clothes. 

Any  article  of  furniture  used  for  sitting  or  lying. 

Any  narcotic  substance. 

54.     YELLOW 

Word  which  may  be  used  to  denote  subjective  characterization  of  the 

yellow  color. 
Any  object  or  substance  which  is  always  or  often  yellow  in  color. 
Any  color  or  coloring  material. 

55.     BREAD 

Any  article  of  food;  any  meal. 

Any  article  of  table  linen,  china,  or  silver;  any  cooking  utensil. 

Any  private  or  pubHc  eating  place. 

Word  pertaining  to  ingestion  and  assimilation  of  food. 

Any  ceremony  in  connection  with  which  bread  is  used. 

56.      JUSTICE 

Any  word  implying  crime  or  tendency  to  crime,  legal  trial,  retribution 

or  lack  of  it,  or  repentance. 
Any  officer  of  the  law. 
Word  pertaining  to  judiciary  organization. 
Word  denoting  any  kind  of  ethical  relationship. 
Any  deity. 

The  name  of  any  justice  or  judge. 
Any  function  of  a  judicial  authority. 
Any  word  denoting  or  implying  equality. 

57.      BOY 

Word  denoting  or  implying  age  of  a  person. 

Word  pertaining  to  familial  relationships  or  domestic  organization. 
Word  pertaining  to  sexual  relationships;   any  word  denoting  the  oppo- 
site sex. 


APPENDIX  TO  THE  FREQUENCY  TABLES  613 

Common  or  proper  name  of  any  male  person. 

Any  part  of  a  person's  body. 

Any  article  of  male  apparel. 

Any  common  boys'  toy  or  game. 

Word  pertaining  to  educational  organization. 

58.     LIGHT 

Any  source,  apparatus,  or  means  of  illumination. 

Any  color  or  coloring  material. 

Word  implying  light  through  incandescence. 

Any  term  of  optics;  any  optical  phenomenon. 

Any  object  or  substance  which  is  characteristically  light  in  weight. 

59.      HEALTH 

Any  emotion;  any  common  manifestation  of  emotion. 
Any  disease  or  symptom. 

Word  pertaining  to  prevention  or  treatment  of  disease. 
Word  pertaining  to  any  normal  bodily  function. 
Word  pertaining  to  the  preservation  of  health. 
Word  denoting  or  implying  a  state  of  health. 
Anj^  athletic  sport  or  form  of  exercise. 
Any  anatomical  organ  or  region. 

60.      BIBLE 

Name  of  any  personage  mentioned  in  the  Bible. 

Any  religion  or  religious  denomination. 

Any  name  or  attribute  employed  in  reference  to  the  Deity. 

Any  article  or  act  of  religious  ritual. 

Word  denoting  or  implying  belief,  disbeUef,  or  doubt. 

Any  term  of  theology. 

61.     MEMORY 

Word  pertaining  to  operations,  faculties,  endowment,  training,  or  con- 
dition of  the  mind. 
Word  denoting  any  degree  of  accuracy. 

Word  denoting  the  cranium;  any  part  of  the  psychical  organ. 
Word  pertaining  to  the  past. 
Any  word  implying  transiency. 

Any  subject  of  study  involving  the  exercise  of  memory. 
Any  method  or  means  for  the  reinforcement  of  memory. 
Any  of  the  senses. 
Word  denoting  retention. 


614  FREE  ASSOCIATION  TEST 

62.      SHEEP 

Any  animal  raised  or  hunted  for  clothing  material,  for  food,  or  for  its 

services  as  a  beast  of  burden. 
Any  product  manufactured  from  the  skin  or  wool  of  sheep. 
Any  of  the  more  or  less  distinctive  characteristics  of  sheep. 
Any  food  product  derived  from  sheep. 

63.     BATH 

Word  denotiag  or  implying  an  effect  of  bathing  on  the  body. 

Any  body  of  water. 

Any  kind  of  bath;  any  part  of  bath,  lavatory,  or  toilet  equipment. 

Any  material  of  which  a  bathing  equipment  is  largely  made. 

Word  denoting  a  state  of  partial  or  complete  undress. 

Any  beach  or  bathing  resort. 

Any  aquatic  feat  of  gymnastics. 

64.      COTTAGE 

Word  pertaroing  to  landscape  gardening. 

Any  place  of  cottage  location. 

Any  part  of  a  house;  any  color. 

Any  material  used  in  the  construction  of  a  cottage. 

Any  laborer  or  mechanic  having  to  do  with  the  construction  of  a  cottage. 

Any  part  of  the  process  of  construction  of  a  cottage. 

Any  commercial  term  pertaining  to  ownership,  taxes,  mortgages,  sale, 

renting,  or  occupancy  of  a  cottage. 
Any  article  of  furniture. 

65.     SWIFT 

Any  means  or  manner  of  locomotion. 

Word  denoting  or  implying  motion  or  rate  of  motion. 

Any  animal  or  familiar  object  characterized  by  rapid  locomotion. 

Any  word  clearly  related  to  the  word  Swift  used  as  a  proper  name. 

66.     BLUE 

Word  which  may  be  used  to  express  subjective  characterization  of  the 

blue  color. 
Any  object  or  substance  which  is  always  or  often  blue  in  color. 
Anjdihing  which  is  by  convention  or  common  usage  connected  with  the 

blue  color. 
Any  organ,  tissue,  or  lesion,  exposed  to  view,  which  may  have  a  blue 

color  imparted  to  it  by  the  blood  or  by  physiological  pigment. 
Any  color  or  coloring  material. 


APPENDIX  TO  THE  FREQUENCY  TABLES  615 

67.  HUNGRY 

Any  animal. 

Any  article  of  food;  any  meal. 

Word  denoting  taste  or  flavor. 

Word  denoting  or  implying  privation  or  torture. 

Any  article  of  table  linen,  china,  or  silver. 

Any  private  or  public  eating  place. 

Any  organ  of  digestion;  any  function  of  nutrition. 

Word  designating  any  person  engaged  in  the  preparation  or  sale  of  foods. 

68.  PBIEST 

Any  religion  or  denomination. 

Any  article  or  act  of  religious  ritual. 

Any  term  of  theology. 

Word  denoting  or  implying  sanctity. 

Word  denoting  or  implying  belief,  disbelief,  or  doubt. 

Word  pertaining  to  church  organization. 

Proper  name  of  any  priest. 

Any  article  of  clerical  attire. 

Any  profession  more  or  less  peculiarly  masculine. 

69.  OCEAN 

Any  body  of  water. 

Any  plant  or  animal  living  in  the  ocean. 

Any  term  of  physical  geography. 

Any  vessel  or  contrivance  for  navigation. 

Word  pertaining  to  navigation ;  any  nautical  term. 

Common  or  proper  name  of  any  place  bordering  on  the  ocean. 

Any  aquatic  feat  of  gymnastics. 

70.     HEAD 

Any  organization  which  has  a  person  occupying  the  highest  office. 

Word  denoting  or  implying  the  highest  office  of  any  organization. 

Any  intellectual  faculty,  quality,  or  operation. 

Any  part  of  the  head. 

Any  pathological  condition  affecting  the  head. 

71.      STOVE 

Any  part  of  a  stove. 

Any  kitchen  utensil. 

Any  artificial  heating  apparatus;  any  fuel. 

Any  manner  of  cooking;  any  person  engaged  in  cooking  food. 

Any  article  of  household  furniture. 


616  FREE  ASSOCIATION  TEST 


73.     LONG 


Any  word  involving  the  concept  of  duration. 

Word  denoting  shape,  relative  or  absolute  dimension,  or  distance. 

Any  object  in  which  characteristically  one  dimension  exceeds  any  other. 

73.  RELIGION 

Any  religion  or  denomination;  the  name  of  any  race  or  nation. 

Any  term  of  theology. 

Any  branch  of  metaphysical  philosophy. 

74.  WHISKEY 

Any  beverage;  the  name  of  any  brand  of  whiskey. 

Any  material  of  which  whiskey  is  made. 

Word  denoting  taste  or  flavor. 

Any  occasion  or  ceremony  commonly  associated  with  the  use  of  alcoholic 

beverages. 
Word  denoting  a  state  of  lowered  consciousness. 
Any  physiological  or  pathological  effect  of  alcohol;  also  any  well-known 

indirect  effect. 

75.      CHILD 

Word  denoting  or  implying  age  of  a  person. 

Word  pertaining  to  famihal  relationships  or  domestic  organization. 

Name  of  any  person. 

Any  part  of  a  person's  body. 

Any  article  of  a  child's  apparel. 

Any  common  child's  toy  or  game. 

Word  pertaining  to  educational  organization. 

Any  word  descriptive  of  the  natural  physical  or  mental  make-up  of  a 

child,  or  of  the  rate  or  degree  of  physical  or  mental  development. 
Word  pertaining  to  any  custom  or  ceremony  connected  with  the  birth 

or  rearing  of  children. 
Any  term  of  obstetrics. 
Any  word  clearly  related  to  the  word  Child  used  as  a  proper  name. 

76.     BITTER 

Any  substance  having  a  bitter,  sour,  sweet,  or  salt  taste,  or  a  complex 
taste  quality  which  may  be  characterized  as  strong. 

Word  denoting  a  taste  or  flavor  quality. 

Any  organ  of  taste. 

Any  word  in  connection  with  which  the  word  bitter  may  be  used  in  the 
sense  of  poignant. 


APPENDIX  TO  THE  FREQUENCY  TABLES  617 

77.  HAMMER 

Any  tool  or  weapon. 

Any  trade  involving  the  use  of  a  hammer. 

78.  THIRSTY 

Any  beverage. 

Any  animal. 

Word  denoting  taste  or  taste  quality. 

Any  part  of  the  upper  end  of  the  digestive  tract. 

Any  drinking  place;  any  container  of  a  beverage. 

Any  fruit;  any  dessert. 

Any  food  ingredient  commonly  known  to  excite  thirst. 

79.      CITY 

Name  of  any  division  of  political  geography. 

Any  architectural  structure. 

Any  part  of  a  city. 

Word  pertaining  to  the  political  organization  of  a  city. 

80.      SQUARE 

The  name  of  any  city. 

The  name  of  any  square  in  a  city  or  town. 

Any  geometrical  figure  or  part  of  one. 

Any  object  that  is  always  or  often  square  in  shape. 

Any  device  used  in  the  arts  for  measuring  angles,  arcs,  or  distances 

between  points. 
Any  part  of  a  carpenter's  or  draughtsman's  square. 
Any  trade  involving  the  use  of  the  square. 

81.      BUTTER 

Any  article  of  food;  any  meal. 

Any  article  of  table  linen,  china,  or  silver;  any  cooking  utensil. 

Any  process  of  cooking. 

83.      DOCTOR 

The  name  of  any  physician. 

Any  medical  specialty  or  practice. 

Any  medical  or  surgical  procedure. 

Any  therapeutic  remedy  or  method. 

Any  organization  for  the  treatment  of  disease. 

Name  of  any  injury  or  disease. 


618  FREE  ASSOCIATION  TEST 

83.  LOUD 

Any  sound  or  sound  quality. 

Any  part  of  the  human  vocal  apparatus. 

Any  act  of  vocalization. 

Any  musical  instrument. 

Any  apparatus  for  making  sound  signals. 

Word  denoting  renown  or  commendation. 

84.  THIEF 

Word  denoting  crime  or  wrongdoing. 

Word  denoting  any  circumstance  propitious  for  theft. 

Any  common  measure  for  the  prevention  or  punishment  of  crime. 

Any  judicial,  police,  or  penal  authority. 

Any  readily  portable  article  of  value. 

Word  denoting  renown. 

85.  LION 

Word  denoting  or  implying  fear. 
Any  animal. 

86.  JOT 

Word  denoting  a  state,  quality,  faculty,  or  function  of  the  mind. 

Any  common  manifestation  of  emotion. 

Any  occasion,  act,  or  means  of  recreation  or  of  pleasurable  excitement. 

87.  BED 

Anj-^  article  of  bedding,  bed  linen,  or  night-clothes. 

Any  article  of  furniture. 

Any  living  room,  apartment,  or  building. 

Any  part  of  a  room. 

Any  division  of  the  diurnal  cycle. 

Any  material  of  which  beds  are  made. 

Word  pertaining  to  sleep  or  rest. 

88.  HEAVY 

Word  denoting  or  implying  weight  or  lightness. 

Any  object  or  substance  which  characteristically  possesses  the  quality 

of  either  great  weight  or  marked  lightness. 
Any  means  of  support  or  suspension. 
Any  fabric;  any  article  of  clothing  or  bedding. 
Word  denoting  something  to  be  carried  or  transferred. 
Any  painful  emotion. 
Word  denoting  a  state  of  lowered  consciousness. 


APPENDIX  TO  THE  FREQUENCY  TABLES  619 

89.      TOBACCO 

The  name  of  any  brand  or  variety  of  tobacco. 

Term  denoting  any  common  quality  of  tobacco. 

Any  physiological  or  pathological  effect  of  tobacco. 

Any  word  which  expresses  subjective  characterization  of  tobacco. 

90.     BABY 

Word  denoting  or  implying  age  or  size  of  a  person. 

Word  pertaining  to  famiUal  relationships  or  domestic  organization. 

Name  of  any  person. 

Any  part  of  a  person's  body. 

Any  article  of  a  child's  apparel. 

Anj''  common  child's  toy  or  game. 

Word  pertaining  to  any  custom  or  ceremony  connected  with  the  birth 

or  rearing  of  children. 
Any  term  of  obstetrics. 

91.     MOON 

Any  term  of  astronomy. 

Word  denoting  or  implying  illumination  or  obscuration  of  light. 

Any  division  of  the  dim-nal  cycle. 

93.      SCISSORS 

Any  operation  or  handicraft  involving  the  use  of  scissors. 

Any  fabric;  any  article  of  clothing. 

Any  metal  of  which  scissors  are  made. 

Any  tool  for  cutting,  piercing,  or  sharpening. 

Any  operation  of  cutting,  piercing,  or  sharpening. 

93.  QUIET 

Any  place  where  silence  usually  prevails  or  is  enforced. 

Word  denoting  or  implying  a  state  of  lowered  psychical  activity  or  of 

psychical  inhibition. 
Word  denoting  heightened  psychical  activity. 
Any  word  pertaining  to  the  emotions. 

94.  GREEN 

Word  which  may  be  used  to  express  subjective  characterization  of  the 

green  color. 
Any  object  or  substance  which  is  always  or  often  green  in  color. 
Anything  which  is  by  convention  or  common  usage  connected  with  the 

green  color. 
Any  color  or  coloring  material. 


620  FREE  ASSOCIATION  TEST 

Any  plant,  collection  of  plants,  or  part  of  a  plant. 

Any  word  clearly  related  to  the  word  Green  used  as  a  proper  name. 

95.      SALT 

Any  article  of  food  that  is  usually  seasoned  with  sajt;   any  seasoning; 

any  relish. 
Any  article  of  table  linen,  china,  or  silver. 
Any  process  of  cooking. 
Any  term  of  chemistry. 

96.      STREET 

Name  of  any  street  or  city. 
Any  part  of  a  street. 
Any  building. 

Any  manner  or  means  of  locomotion  commonly  employed  in  traveling 
through  streets. 

97.     KING 

Any  name  of  the  Deity. 

The  proper  or  common  name  of  any  ruler  of  a  nation  or  of  a  smaller 

municipality. 
Any  nation  or  country. 
Any  title  of  nobility. 
Any  word  clearly  related  to  the  word  King  used  as  a  proper  name. 

98.      CHEESE 

Any  article  of  food;  any  meal. 

Word  denoting  any  variety  of  cheese. 

Word  pertaining  to  taste,  flavor,  or  odor. 

Word  pertaining  to  appetite. 

Any  article  of  table  linen,  china,  or  silver. 

99.     BLOSSOM 

Any  plant,  collection  of  plants,  or  part  of  a  plant. 

Any  term  of  botany. 

Any  division  of  the  annual  cycle. 

100.     AFRAII) 

Any  affective  state;  any  common  demonstration  of  emotion. 
Any  common  object  of  fear. 

Word  denoting  or  implying  danger,  courage;    any  means  of  defense  or 
protection  against  danger. 


APPENDIX  VII 


STANDARD  PSYCHOLOGICAL  GROUP  TESTS 

The  following  tests  can  be  applied  not  only  to  individual 
subjects,  but  also  to  groups  of  subjects.  They  can  be  best 
conducted  in  a  classroom  containing  the  usual  equipment  of 
desks,  blackboards,  etc. 

Tests  1  and  2  require  no  materials  other  than  writing 
materials  for  each  subject.  The  materials  required  for  tests 
3  to  7  consist  in  printed  forms  which  may  be  purchased  in 
packages  of  25  from  The  Morningside  Press,  417  West 
118th  Street,  New  York. 

The  following  table  gives  the  age  norms  for  each  test 
established  by  application  to  large  numbers  of  subjects: 

TABLE  21 


Ages  in  Years. 


10 


11 


12 


1.  Digit  span,  1  of  3 

2.  Logical  memory,  points. .  .  .  , 

3.  Cancelling  A,  in  1  minute. .  . 

4.  Completion,  Trabue  A 

5.  Opposites,  in  1  minute 

6.  Part-whole,  in  1  minute 

7.  Word  building,  in  5  minutes, 


4 
3 
16 
0 
0 
0 
0 


5 
17 
23 
4 
2 
0 
1 


5 
25 

27 
8 
7 
5 
.4 


5 
31 
30 
12 

8 
6 
5 


6 
34 
35 
16 


6 
38 
38 
20 
10 

9 


6 
41 
42 
24 
12 
10 

9 


Ages  in  Years. 

13 

14 

15 

16 

17 

18 

1.  Digit  span,  1  of  3 

6 
43 
48 
28 
14 
11 
11 

7 
44 
50 
32 
15 
12 
12 

7 
44 
54 
36 
16 
15 
13 

7 
45 
57 
40 
17 
16 
14 

7 
45 
59 
44 
19 
18 
■  16 

8 

2.  Logical  memory,  points 

3.  Cancelling  A,  in  1  minute 

4.  Completion,  Trabue  A 

50 
60 
48 

5.  Opposites,  in  1  minute 

20 

6.  Part-whole,  in  1  minute 

7.  Word  building,  in  5  minutes. .  .  . 

19 

18 

621 


622        STANDARD  PSYCHOLOGICAL  GROUP  TESTS 

Test  1.  Digit  Span. — Instructions. — "Now  I  am  going 
to  say  some  easy  numbers.  Listen  to  them  carefully,  and 
when  I  am  through  I  want  you  to  write  them  down  in  the  same 
order  as  given."  Illustrate  by  a  simple  example.  Then 
take  in  sequence  the  following  groups  of  digits,  calUng  them 
clearly,  at  the  standard  rate  of  one  per  second : 


I 


Set  A 

SetB 

SetC 

641 

352 

837 

4739 

2854 

7261 

42835 

31759 

98176 

374859 

521746 

417925 

9728475 

2813439 

4162593 

72534896 

49853762 

95423718 

438923517 

981725436 

629471583 

Scoring. — The  score  is  the  largest  number  of  digits  a 
subject  can  repeat,  once  out  of  three  different  trials,  as 
above. 

Test  2.  Logical  Memory. — Instructions. — "Now  I  am 
going  to  see  how  well  you  can  remember  things.  I  shall  read 
some  words  to  you,  several  in  a  group.  When  I  have  finished, 
try  to  write  them  down  in  exactly  the  same  order  that  I  gave 
them.  If  you  cannot  remember  some  of  the  words,  make  a 
mark  where  each  of  them  goes,  and  put  in  the  proper  places 
all  the  other  words  you  can  remember."  Read  the  words 
clearly,  not  more  rapidly  than  one  per  second.  Use  the 
following: 

A — street,  ink,  lamp. 

B — spoon,  horse,  chair,  stone. 

C — ground,  clock,  boy,  chalk,  book. 

D — desk,  milk,  hand,  card,  floor,  cat. 

E — ball,  cup,  glass,  hat,  fork,  pole,  cloud. 

F — coat,  girl,  house,  salt,  glove,  watch,  box,  mat. 

Scoring. — A  credit  of  2  points  is  allowed  for  each  correct 
word  in  the  right  position,  1  point  being  allowed  for  a  cor- 
rect word  not  in  the  right  position.  There  are  33  words, 
hence  the  maximum  score  is  66  points.  Credit  any  word 
that    resembles    closely  in  sound    the    correct  word    (thus 


CANCELLATION— COMPLETION— OPPOSITES        623 

"cut"  for  "cup,"  "mill"  for  "milk").  Disregard 
spelling. 

Test  3.  Cancellation. — Instructions. — Put  the  paper 
before  the  subject  with  the  printed  side  down.  Say: 
"  When  you  turn  the  paper  over  you  will  find  a  lot  of  letters, 
all  mixed  up.  You  must  draw  a  line  like  this  (illustrate) 
through  every  A  that  you  can  find.  Mark  out  every  A,  but 
do  nothing  to  the  other  letters.  I  want  to  see  how  many  A's 
you  can  mark  out  in  one  minute.  Do  you  understand?  All 
ready,  go." 

Scoring. — The  score  is  the  number  of  A's  cancelled  in  one 
minute.  Ignore  errors,  both  omissions  and  cancellations 
of  wrong  letters. 

Test  4.  Completion. — Instructions. — "  See  what  it  says 
at  the  top  of  the  page.  On  each  blank  write  the  word  which 
makes  the  best  meaning.  Only  one  word  on  each  blank. 
Wherever  there  is  a  blank  some  word  has  been  left  out.  You 
are  to  write  the  word  in  each  place  so  that  there  will  be  a  good 

meaning.     (Illustrate,  using  the  sentence  "  See  the 

dog.")  Where  there  are  two  blanks  you  must  use  two  words. 
Do  as  many  of  them  as  you  can.  You  have  twenty  minutes 
for  this." 

Scoring. — Grade  each  sentence  2,  1  or  0,  giving  2  for  a 
perfect  meaning,  1  for  an  inferior  but  acceptable  meaning, 
and  0  for  failure  or  incompleteness  or  meaninglessness. 
Ignore  spelHng.  The  score  is  the  total  number  of 
points. 

Test  5.  Opposites. — Instructions. — "  When  you  turn  the 
paper  over  you  will  find  on  the  other  side  a  list  of  words,  with  an 
empty  space  for  you  to  write  something  beside  each  word.  You 
are  to  write  beside  each  word  the  word  that  means  just  the  oppo- 
site of  that  word.  If  the  first  word  is  "  long  "  what  will  you 
write?  If  the  next  word  is  "  up  "  what  will  you  write?  Now 
do  you  understand?  If  you  can't  think  of  a  word  right  aivay, 
just  go  on  to  the  next.  I  want  to  see  how  many  you  can  do  in 
one  minute.  All  ready,  go."  The  words  on  the  standard 
Ust  are  as  follows:    good,  outside,  quick,  tall,  big,  loud, 


624       STANDARD  PSYCHOLOGICAL  GROUP  TESTS 

white,  light,  happy,  false,  like,  rich,  sick,  glad,  thin,  empty, 
war,  many,  above,  friend. 

Scoring. — The  score  is  the  nmnber  of  correct  opposites, 
giving  credit  for  every  word  that  could  by  any  possible 
means  be  considered  an  opposite  of  a  test  word,  except  that 
adverbs  or  nouns  are  not  credited  for  adjectives,  nor  adjec- 
tives for  nouns. 

Test  6.  Part- Whole. — Instructions. — "  When  you  turn 
the  paper  over  you  will  find  twenty  words,  each  of  which  names 
a  part  of  something.  You  are  to  write  after  each  word  some 
word  that  means  the  whole  of  the  thing.  For  example,  if  one 
word  were  "  wheel  "  you  could  write  "  engine,''  because  a  wheel 
is  a  part  of  an  engine.  Or  if  one  word  were  "toe"  you  could 
write  "foot  "  because  a  toe  is  a  part  of  a  foot.     All  ready,  go." 

Scoring. — The  score  is  the  number  of  correct  responses 
given  in  one  minute.  The  words  are:  window,  leaf,  pillow, 
button,  nose,  smokestack,  cog-wheel,  cover,  letter,  petal, 
page,  cob,  axle,  lever,  blade,  sail,  coach,  cylinder,  beak, 
stamen. 

Test  7.  Word  Building. — Instructions. — "  You  see  these 
letters?  A-E-I-R-L-P.  You  can  make  words  out  of  these 
letters.  For  example  you  can  say  E-A-R,  "  ear  "  and  that 
is  a  word.  But  could  you  say  R-A-T  "  rat"f  No,  because 
there  is  no  T  there.  Could  you  say  P-I-L-L,  "  pill  "f  No, 
because  there  is  only  one  L  there.  So  you  must  make  as  many 
words  as  you  can  from  just  these  letters.  Do  not  use  any  letters 
that  are  not  there.  Do  not  use  any  letter  more  than  once  in  the 
same  word.  Do  you  understand?  Now  I  am  going  to  let  you 
have  five  minutes,  and  I  want  to  see  how  many  words  you  can 
make.     Write  them  all  on  the  paper.     Ready,  go." 

Scoring. — The  score  is  the  number  of  words  correct 
(and  correctly  spelled)  excluding  obsolete  and  foreign  words, 
and  abbreviations.    About  60  words  are  possible. 


I 


APPENDIX  VIII 

CLASSIFICATION  OF  MENTAL  DISEASES  ADOPTED  BY  THE 
AMERICAN  MEDICO-PSYCHOLOGICAL  ASSOCIATION 
MAY  30,  1917,  AND  BY  THE  NEW  YORK  STATE  HOSPITAL 
COMMISSION  JULY  1,  1917  i 

1.  Traumatic  psychoses, 
(a)  Traumatic  delirium. 
(6)  Traumatic  constitution, 
(c)   Post-traumatic  mental  enfeeblement. 

2.  Senile  Psychoses. 

(a)  Simple  deterioration. 
(6)  Presbyophrenic  type. 

(c)  Delirious  and  confused  states. 

(d)  Depressed  and  agitated  states  in  addition  to  de- 

terioration. 

(e)  Paranoid  states. 
(/)    Pre-senile  types. 

3.  Psychoses  with  Cerebral  Arteriosclerosis. — (This  in- 
cludes psychoses  following  cerebral  softenings  or  hemorrhage 
if  due  to  arterial  disease.) 

4.  General  paralysis. 

(a)  Tabetic  type. 
(6)  Cerebral  type. 

5.  Psychoses  with  Cerebral  Syphilis. 

6.  Psychoses  with  Huntington's  Chorea. 

7.  Psychoses  with  Brain  Tumor. 

1  Reprinted  by  permission  from  the  Statistical  Guide  of  the  New  York 
State  Hospital  Commission,  fourth  edition,  Utica,  1918. 

625 


626  OFFICIAL  CLASSIFICATION 

S.  Psychoses  with  other  Bram  or  Nervous  Diseases. — 

(The  following  are  the  more  frequent  of  these  diseases  and 
should  be  specified  in  the  diagnosis) : 

Cerebral  embolism. 

Paralysis  agitans. 

Meningitis,  tubercular  or  other  forms  (to  be  specified). 

Multiple  sclerosis. 

Tabes. 

Acute  chorea. 

Other  conditions  (to  be  specified). 

9.  Alcoholic  Psychoses. 

(a)  Pathological  intoxication. 
(6)  Delirium  tremens. 

(c)  Korsakow  psychoses. 

(d)  Acute  hallucinosis. 

(e)  Chronic  hallucinosis. 
(/)   Acute  paranoid  type. 
(g)  Chronic  paranoid  type. 
(h)  Alcoholic  deterioration. 

(i)   Other  types,  acute  or  chronic. 

10.  Psychoses  Due  to  Drugs  and  other  Exogenous  Toxins. 

(a)  Opium    (and    derivatives),    cocaine,    bromides, 

chloral,  etc.,  alone  or  combined  (to  be  specified). 

(b)  Metals,  as  lead,  arsenic,  etc.  (to  be  specified). 

(c)  Gases  (to  be  specified). 

(d)  Other  exogenous  toxins  (to  be  specified). 

11.  Psychoses  with  Pellagra. 

12.  Psychoses  with  other  Somatic  Diseases. 

(a)  Delirium  with  infectious  disease  (specify). 
(h)  Post-infectious  psychosis. 

(c)  Exhaustion-delirium. 

(d)  Delirium  of  unknown  origin. 

(e)  Cardio-renal  diseases. 

(/)   Diseases  of  the  ductless  glands. 

(g)  Other  diseases  or  conditions  (to  be  specified). 


CLINICAL  GROUPS  627 

13.  Manic-Depressive  Psychoses. 

(a)  Manic  tj^pe. 
(6)  Depressive  type. 

(c)  Stupor. 

(d)  Mixed  type. 

(e)  Circular  type. 

14.  Involution  Melancholia. 

15.  Dementia  Praecox. 

(a)  Paranoid  type. 
(6)  Catatonic  type. 

(c)  Hebephrenic  type. 

(d)  Simple  type. 

16.  Paranoia  or  Paranoic  Conditions. 

17.  Epileptic  Psychoses. 

(a)  Deterioration. 

(6)  Clouded  states.  , 

(c)  Other  conditions  (to  be  specified). 

18.  Psychoneuroses  and  Neuroses. 

(a)  Hysterical  type. 
(6)  Psychasthenic  type. 

(c)  Neurasthenic  type. 

(d)  Anxiety  neuroses. 

19.  Psychoses  with  Constitutional  Psychopathic  Inferi- 
ority. 

20.  Psychoses  with  Mental  Deficiency. 

21.  Undiagnosed  Psychoses. 

22.  Not  Insane. 

(a)  EpUepsy  without  psychosis. 
(6)  Alcoholism  without  psychosis. 

(c)  Drug  addiction  without  psychosis. 

(d)  Constitutional  psychopathic  inferiority  without 

psychosis. 

(e)  Mental  deficiency  without  psychosis. 
(/)  Others  (to  be  specified). 


628  OFFICIAL  CLASSIFICATION 

Definitions  and  Explanatory  Notes 

The  definitions  and  explanatory  notes  accompanying 
the  classification  were  prepared  by  Dr.  George  H.  Kirby, 
Director  of  the  Psychiatric  Institute,  Ward's  Island,  N.  Y. 

1.  Traiimatic  Psychoses. — The  diagnosis  should  be  restricted  to 
those  mental  disorders  arising  as  a  direct  or  obvious  consequence  of 
brain  (or  head)  injury  which  produces  psychotic  symptoms  of  a  fairly 
characteristic  kind.  The  amount  of  damage  to  the  brain  may  vary 
from  an  extensive  destruction  of  tissue  to  simple  concussion  or  physical 
shock  with  or  without  fracture  of  the  skull. 

Manic-depressive  psychosis,  general  paralysis,  dementia  prsecox, 
and  other  mental  disorders  in  which  trauma  may  act  as  a  contributory 
or  precipitating  cause,  should  not  be  included  in  this  group. 

The  following  are  the  most  common  clinical  types  of  traumatic 
psychosis  and  should  be  specified  in  the  statistical  report : 

(a)  Traumatic  delirium:  This  may  take  the  form  of  an  acute 
deUrium  (concussion  delirium),  or  a  more  protracted  delirium  resembling 
the  Korsakow  mental  complex. 

(b)  Traumatic  constitution:  ChgRracterized  by  a  gradual  post- 
traumatic change  in  disposition,  with  vasomotor  instability,  headaches, 
fatigability,  irritability  or  explosive  emotional  reactions;  usually 
hyper-sensitiveness  to  alcohol,  and  in  some  cases  development  of 
paranoid,  hy steroid  or  epileptoid  symptoms. 

(c)  Post-traumatic  mental  enfeeblement  (dementia):  Varying 
degrees  of  mental  reduction  with  or  without  aphasic  symptoms,  epilep- 
tiform attacks  or  development  of  a  cerebral  arteriosclerosis. 

2.  Senile  Psychoses. — A  well-defined  type  of  psychosis  which  as  a 
rule  develops  gradually  and  is  characterized  by  the  following  symptoms : 

Impairment  of  retention  (forgetfulness)  and  general  failure  of 
memory  more  marked  for  recent  experiences;  defects  in  orientation 
and  a  general  reduction  of  mental  capacity:  the  attention,  concentra- 
tion and  thinking  processes  are  interfered  with;  there  is  self-centering 
of  interests,  often  irritability  and  stubborn  opposition;  a  tendency  to 
reminiscence  and  fabrication.  Accompanying  this  deterioration  there 
may  occur  paranoid  trends,  depressions,  confused  states,  etc.  Certain 
clinical  types  should  therefore  be  specified,  but  these  often  overlap: 

(a)  Simple  deterioration:  Retention  and  memory  defects,  reduc- 
tion in  intellectual  capacity  and  narrowing  of  interests;  usually  also 
suspiciousness,  irritability  and  restlessness,  the  latter  particularly  at 
night. 

(6)  Presbyophrenic  type:  Severe  memory  and  retention  defects 
with  complete  disorientation;    but  at  the  same  time  preservation  of 


DEFINITIONS  AND  EXPLANATORY  NOTES  629 

mental  alertness  and  attentiveness  with  ability  to  grasp  immediate 
impressions  and  conversation  quite  well.  Forgetfulness  leads  to  absurd 
contradictions  and  repetitions;  suggestibility  and  free  fabrication  are 
prominent  symptoms.  (The  general  picture  resembles  the  Korsakow 
mental  complex.) 

(c)  Delirious  and  confused  types:  Often  in  the  early  stages  of  the 
psychosis  and  for  a  long  period  the  picture  is  one  of  deep  confusion  or  a 
delirious  condition. 

(d)  Depressed  and  agitated  types:  In  addition  to  the  underlying 
deterioration  there  may  be  a  pronounced  depression  and  persistent 
agitation. 

(e)  Paranoid  types:  Well-marked  delusional  trends,  chiefly  per- 
secutory or  expansive  ideas,  often  accompany  the  deterioration  and 
in  the  early  stages  may  make  the  diagnosis  difficult  if  the  defect  symp- 
toms are  mild. 

(/)  Pre-senUe  types:  The  so-called  "Alzheimer's  disease";  an 
early  senile  deterioration  which  usually  leads  rapidly  to  a  deep  dementia. 
Reported  to  occur  as  early  as  the  fortieth  year.  Most  cases  show  an 
irritable  or  anxious  depressive  mood  with  aphasic  or  apractic  symptoms. 
There  is  apt  to  be  general  resistiveness  and  sometimes  spasticity. 

3.  Psychoses  with  Cerebral  Arteriosclerosis. — The  clinical  symp- 
toms, both  mental  and  physical,  are  varied,  depending  in  the  first  place 
on  the  distribution  and  severity  of  the  vascular  cerebral  disease  and 
probably  to  some  extent  on  the  mental  make-up  of  the  person. 

Cerebral  physical  symptoms,  headaches,  dizziness,  fainting  attacks, 
etc.,  are  nearly  always  present  and  usually  signs  of  focal  brain  disease 
appear  sooner  or  later  (aphasia,  paralysis,  etc.). 

The  most  important  mental  symptoms  (particularly  if  the  arterio- 
sclerotic disease  is  diffuse)  are  impairment  of  mental  tension,  i.e.,  inter- 
ference with  the  capacity  to  think  quickly  and  accurately,  to  concen- 
trate and  to  fix  the  attention ;  fatigability  and  lack  of  emotional  control 
(alternate  weeping  and  laughing).  Often  a  tendency  to  irritability  is 
marked;  the  retention  is  impaired  and  with  it  there  is  more  or  less 
general  defect  of  memory,  especially  in  the  advanced  stages  of  the  dis- 
ease, or  after  some  large  destructive  lesion  occurs. 

Pronounced  psychotic  symptoms  may  appear  in  the  form  of  de- 
pression (often  of  the  anxious  type),  suspicions  or  paranoid  ideas, 
or  episodes  marked  by  confusion. 

To  be  included  in  this  group  are  the  psychoses  following  cerebral 
softening  or  hemorrhage  if  due  to  arterial  disease.  (Autopsies  in  state 
hospitals  show  that  in  arteriosclerotic  cases  softening  is  relatively  much 
more  frequent  than  hemorrhage.) 

Differentiation  from  senile  psychosis  is  sometimes  difficult,  par- 
ticularly if  the  arteriosclerotic  disease  manifests  itself  in  the  senile 


630  OFFICIAL  CLASSIFICATION 

period.  The  two  conditions  may  be  associated;  when  this  happens 
preference  should  be  given  in  the  statistical  report  to  the  arteriosclerotic 
disorder. 

High  blood  pressure,  although  usually  present,  is  not  essential  for 
the  diagnosis  of  cerebral  arteriosclerosis. 

4.  General  Paralysis. — The  range  of  sjTnptoms  encoiintered  in 
general  paralysis  is  too  great  to  be  reviewed  here  in  detail.  As  to 
mental  sj-mptoms,  most  stress  should  be  laid  on  the  early  changes 
in  disposition  and  character,  judgment  defects,  difficulty  about  time 
relations  and  discrepancies  in  statements,  forgetfuhiess  and  later 
on  a  diffuse  memory  impairment.  Cases  with  marked  grandiose  trends 
are  less  likely  to  be  overlooked  than  cases  with  depressions,  paranoid 
ideas,  alcohoHc-like  episodes,  etc. 

Mistakes  of  diagnosis  are  most  apt  to  be  made  in  those  cases  having 
in  the  early  stages  pronounced  psychotic  sjnnptoms  and  relatively 
shght  defect  symptoms,  or  cases  with  few  definite  physical  signs.  Lmn- 
bar  puncture  should  always  be  made  if  there  is  any  doubt  about  the 
diagnosis.  A  Wassermann  examination  of  the  blood  alone  is  not 
sufficient,  as  this  does  not  teU  us  whether  or  not  the  central  nervous 
system  is  involved. 

From  the  neurological  standpoint  two  tjTDes  may  be  differentiated: 

(a)  Cerebral  form  (with  increased  knee  jerks). 

(b)  Tabetic  form  (diminished  or  absent  knee  jerks). 

5.  Psychoses  with  Cerebral  Syphilis. — Since  general  paralysis 
itself  is  now  known  to  be  a  parenchymatous  form  of  brain  syphiHs,  the 
differentiation  of  the  cerebral  syphilis  cases  might  on  theoretical  grounds 
be  regarded  as  less  important  than  formerly.  Practically,  however, 
the  separation  of  the  non-parenchymatous  forms  is  very  important 
because  the  sjinptoms,  the  course  and  therapeutic  outlook  in  most 
of  these  cases  are  different  from  those  of  general  para^^sis. 

According  to  the  predominant  pathological  characteristics,  three 
types  of  cerebral  sj^Dhilis  may  be  distinguished,  viz.:  (a)  Meningitic, 
(b)  endarteritic,  (c)  gummatous.  The  lines  of  demarcation  between 
these  types  are  not,  however,  sharp  ones.  _  We  practically  always  find 
in  the  endarteritic  and  gummatous  types  a  certain  amount  of  menin- 
gitis. 

The  acute  meningitic  form  is  the  most  frequent  tj^^e  of  cerebral 
sjTihilis  and  gives  little  trouble  in  diagnosis;  many  of  these  cases  do  not 
reach  state  hospitals.  In  most  cases  after  prodromal  symptoms  (head- 
ache, dizziness,  etc.)  there  is  a  rapid  development  of  physical  signs, 
usually  cranial  nerve  involvement,  and  a  mental  picture  of  dullness 
or  confusion  with  few  psychotic  symptoms  except  those  related  to 
a  delirious  or  organic  reaction. 

In  the  rarer  chronic  meningitic  forms  which  are  apt  to  occur  a  long 


DEFINITIONS  AND  EXPLANATORY  NOTES         631 

time  after  the  syphilitic  infection,  usually  in  the  period  in  which  we 
might  expect  general  paralysis,  the  diagnostic  difficulties  may  be  con- 
siderable. 

In  the  endarteritic  forms  the  most  characteristic  symptoms  are 
those  resulting  from  focal  vascular  lesions. 

In  the  gummatous  forms  the  slowly  developing  focal  and  pressm-e 
symptoms  are  most  significant. 

In  all  forms  of  cerebral  sj'philis  the  psychotic  manifestations  are 
less  prominent  than  in  general  paralysis  and  the  personality  is  much 
better  preserved  as  shown  by  the  social  reactions,  ethical  sense,  judg- 
ment and  general  behavior.  The  grandiose  ideas  and  absurd  trends  of 
the  general  paralytic  are  rarely  encountered  in  these  cases. 

6.  Psychoses  with  Huntington's  Chorea. — Mental  symptoms  are  a 
constant  accompaniment  of  this  form  of  chorea  and  as  a  rule  become 
more  marked  as  the  disease  advances.  Although  the  disease  is  regarded 
as  being  hereditary  in  nature,  a  diagnosis  can  be  made  on  the  clinical 
picture  in  the  absence  of  a  family  history. 

The  chief  mental  symptoms  are  those  of  an  emotional  change,  either 
apathy,  mental  inertia  and  siUiness  or  a  depressive  irritable  reaction 
with  a  tendency  to  passionate  outbursts.  As  the  disease  progresses 
the  memory  is  affected  to  some  extent,  but  the  patient's  ability  to  recall 
past  events  is  often  found  to  be  surprisingly  well  preserved  when  the 
disiucliriation  to  co-operate  and  give  information  can  be  overcome. 
Likewise  the  orientation  is  well  retained  even  when  the  patient  appears 
very  apathetic  and  listless.  Suspicions  and  paranoid  ideas  are  promi- 
nent in  some  cases. 

7.  Psychoses  with  Brain  Tumor. — A  large  majority  of  brain  tumor 
cases  show  definite  mental  symptoms.  Most  frequent  are  mental  dull- 
ness, somnolence,  hebetude,  slowness  in  thinking,  memory  failure, 
irritability  and  depression,  although  a  tendency  to  facetiousness  is 
sometimes  observed.  Episodes  of  confusion  with  hallucinations  are 
common;   some  cases  express  suspicions  and  paranoid  ideas. 

The  diagnosis  must  rest  in  most  cases  on  the  neurological  symptoms, 
and  these  will  depend  on  the  location,  size  and  rate  of  growth  of  the 
tumor.  Certain  general  physical  symptoms  due  to  an  increased  intra- 
cranial pressure  are  present  in  most  cases,  viz.:  headache,  dizziness, 
vomiting,  slowing  of  the  pulse,  choked  disc  and  interlacing  of  the  color 
fields. 

8.  Psychoses  with  Other  Brain  or  Nervous  Diseases. — This  divi- 
sion provides  a  place  for  grouping  a  variety  of  less  common  mental 
disorders  associated  with  organic  disease  of  the  nervous  system  and  not 
included  in  the  preceding  larger  groups.  On  the  card  the  special  type 
of  nervous  disease  should  be  mentioned  after  the  group  name.  The 
following  are  the  conditions  most  frequently  met  with: 


632  OFFICIAL  CLASSIFICATION 

(a)  Cerebral  embolism  (if  an  incident  in  cerebral  arteriosclerosis 
it  should  be  placed  in  group  3) . 
(6)  Paralysis  agitans. 

(c)  Meningitis,  tubercular  or  other  forms  to  be  specified. 

(d)  Multiple  sclerosis. 

(e)  Tabes  (paresis  to  be  carefully  excluded). 

(/)  Acute  chorea  (Sydenham's  type).  Hysterical  chorea  to  be 
excluded. 

ig)  Other  conditions  (to  be  specified). 

9.  Alcoholic  Psychoses. — The  diagnosis  of  alcoholic  psychosis  should 
be  restricted  to  those  mental  disorders  arising  with  few  exceptions  in 
connection  with  chronic  drinking  and  presenting  fairly  well-defined 
symptom-pictures.  We  must  guard  against  making  the  alcoholic  group 
too  inclusive.  Over-indulgence  in  alcohol  is  often  found  to  be  merely  a 
symptom  of  another  psychosis,  or  at  any  rate  may  be  incidental  to 
another  psychosis,  such  as  general  paralysis,  manic-depressive  insanity, 
dementia  prsecox,  epilepsy,  etc.  The  cases  to  be  regarded  as  alcoholic 
psychoses  and  which  do  not  result  from  chronic  drinking  are  the  episodic 
attacks  in  some  psychopathic  personaUties,  the  dipsomanias  (the  true 
periodic  drinkers)  and  pathological  intoxication,  any  one  of  which  may 
develop  as  the  result  of  a  single  imbibition  or  a  relatively  short  spree. 

The  following  alcoholic  reactions  usually  present  symptoms  distinc- 
tive enough  to  allow  of  cUnical  differentiation: 

(a)  Pathological  intoxication:  An  unusual  or  abnormal  immediate 
reaction  to  taking  a  large  or  small  amount  of  alcohol.  Essentially  an 
acute  mental  disturbance  of  short  duration  characterized  usually  by 
an  excitement  or  fiKor  with  confusion  and  hallucinations,  followed  by 
amnesia. 

(6)  Delirium  tremens:  A  hallucinatory  delirium  with  marked 
general  tremor  and  toxic  symptoms. 

(c)  Korsakow's  disease:  This  occurs  with  or  without  polyneuritis. 
The  delirious  t3^es  are  not  readily  differentiated  in  the  early  stages  from 
severe  delirium  tremens  but  are  more  protracted.  The  non-delirious 
type  presents  a  characteristic  retention  defect  with  disorientation, 
fabrication,  suggestibility  and  tendency  to  misidentify  persons.  Hallu- 
cinations are  infrequent  after  the  acute  phase. 

(d)  Acute  hallucinosis:  This  is  chiefly  an  auditory  hallucinosis  of 
rapid  development  with  clearness  of  the  sensorium,  marked  fears,  and 
a  more  or  less  systematized  persecutory  trend. 

(e)  Chronic  hallucinosis:  This  is  an  infrequent  type  which  may 
be  regarded  as  the  persistence  of  the  symptoms  of  the  acute  hallucinosis 
without  change  in  the  character  of  the  symptoms  except  perhaps  a 
gradual  lessening  of  the  emotional  reaction  accompanying  the  halluci- 
nations. 


DEFINITIONS  AND  EXPLANATORY  NOTES         633 

(/)  Acute  paranoid  type:  Suspicions,  misinterpretations,  and  per- 
secutory ideas,  often  a  jealous  trend;  hallucinations  usually  subordi- 
nate; clearing  up  on  withdrawal  of  alcohol. 

(g)  Chronic  paranoid  type:  Persistence  of  symptoms  of  the  acute 
paranoid  type  with  fixed  delusions  of  persecution  or  jealousy  usually 
not  influenced  by  withdrawal  of  alcohol;  difficult  to  differentiate  from 
non-alcoholic  paranoid  states  or  dementia  prajcox. 

(h)  Alcoholic  deterioration:  A  slowly  developing  moral,  volitional 
and  emotional  change  in  the  chronic  drinker;  apparently  relatively 
few  cases  are  committed  as  the  mental  symptoms  are  not  usually  looked 
upon  as  sufficient  to  justify  the  diagnosis  of  a  definite  psychosis.  The 
chief  symptoms  are  iU  humor  and  irascibility  or  a  jovial,  careless, 
facetious  mood;  abusiveness  to  family,  unreliability  and  tendency  to 
prevarication;  in  some  cases  definite  suspicions  and  jealousy;  there  is 
a  general  lessening  of  efficiency  and  capacity  for  physical  and  mental 
work;  memory  not  seriously  impaired.  To  be  excluded  are  cases 
with  residual  defects  due  to  Korsakow's  disease,  or  with  mental  reduc- 
tion due  to  arteriosclerosis  or  to  traumatic  lesions. 

(i)  Other  types  to  be  specified. 

10.  Psychoses  Due  to  Drugs  and  Other  Exogenous  Toxins. — 
The  clinical  pictures  produced  by  drugs  and  other  exogenous  poisons 
are  principally  deliria  or  states  of  confusion ;  although  sometimes  hallu- 
cinatory and  paranoid  reactions  are  met  with.  Certain  poisons  and 
gases  apparently  produce  special  symptoms,  e.g.,  cocaine,  lead,  illumi- 
nating gas,  etc.  Grouped  according  to  the  toxic  etiological  factors  the 
following  are  to  be  differentiated: 

(a)  Opium  (and  derivatives),  cocaine,  bromides,  chloral,  etc.,  alone 
or  combined  (to  be  specified). 

(b)  Metals,  as  arsenic,  lead,  etc.  (to  be  specified). 

(c)  Gases  (to  be  specified) . 

(d)  Other  exogenous  toxins  (to  be  specified) . 

11.  Psychoses  with  Pellagra. — The  relation  which  various  mental 
disturbances  bear  to  the  disease  pellagra  is  not  yet  settled.  Cases 
of  pellagra  occurring  during  the  course  of  a  well-estabhshed  mental 
disease  such  as  dementia  praecox,  manic-depressive  insanity,  senile 
dementia,  etc.,  should  not  be  included  in  this  group.  The  mental  dis- 
tin:bances  which  are  apparently  most  intimately  connected  with  pellagra 
are  certain  delirious  or  confused  states  (toxic-organic-like  reactions) 
arising  during  the  course  of  a  severe  pellagra.  These  are  the  cases 
which  for  the  present  should  be  placed  in  the  group  of  psychoses  with 
pellagra.  Symptoms  of  Meyer's  central  neuritis  should  be  looked  for 
in  these  cases. 

12.  Psychoses  with  Other  Somatic  Diseases. — Under  this  heading 
are  brought  together  those  mental  disorders  which  appear  .to  depend 


634  OFFICIAL  CLASSIFICATION 

directly  on  some  physical  disturbance  or  somatic  disease  not  already 
provided  for  in  the  foregoing  groups. 

In  the  types  designated  below  under  (a)  to  (e)  inclusive,  we  have 
essentially  deliria  or  states  of  confusion  arising  during  the  course  of 
an  infectious  disease  or  in  association  with  a  condition  of  exhaustion 
or  a  toxaemia.  The  mental  disturbance  is  apparently  the  result  of 
interference  with  brain  nutrition  or  the  unfavorable  action  of  certain 
deleterious  substances,  poisons,  or  toxins,  on  the  central  nervous 
system.  The  clinical  pictures  met  with  are  extremely  varied.  The 
delirium  may  be  marked  by  severe  motor  excitement  and  incoherence 
of  utterance,  or  by  multiform  hallucinations  with  deep  confusion  or  a 
dazed,  bewildered  condition;  epileptiform  attacks,  catatonic-like 
symptoms,  stupor,  etc.,  may  occur.  In  classifying  these  psychoses  a 
difficult  problem  arises  in  many  cases  if  attempts  are  made  to  dis- 
tinguish between  infection  and  exhaustion  as  etiological  factors.  For 
statistical  reports  the  following  differentiations  should  be  made: 

Under  (a)  "  Delirium  with  infectious  disease,"  place  the  initial 
deliria  which  develop  during  the  prodromal  or  incubation  period  or 
before  the  febrile  stage  as  in  some  cases  of  typhoid,  small-pox,  malaria, 
etc.;  the  febrile  deliria  which  seem  to  bear  a  definite  relation  to  the  rise 
in  temperature;  the  post-febrile  deliria  of  the  period  of  defervescence 
including  the  so-called  "  collapse  dehrium." 

Under  (b)  "  Post-infectious  psychosis  "  are  to  be  grouped  deliria 
and  mild  forms  of  mental  confusion  or  the  depressive,  irritable,  sus- 
picious reactions  which  occur  during  the  period  of  convalescence 
from  infectious  diseases.  Physical  asthenia  and  prostration  are  un- 
doubtedly important  factors  in  these  conditions  and  differentiation 
from  "  exhaustion  deliria  "  must  depend  chiefly  on  the  history  and  the 
obvious  close  relationship  to  the  preceding  infectious  disease.  (Some 
cases  which  fail  to  recover  show  a  peculiar  mental  enfeeblement.)  In 
this  group  should  be  classed  the  "  cerebi  opathia  psychica  toxcemica  " 
or  the  non-alcoholic  polyneuritic  psychoses  following  an  infectious 
disease  as  typhoid,  influenza,  septicaemia,  etc. 

Under  (c)  "  Exhaustion  dehrium  "  are  to  be  classed  psychoses  in 
which  physical  exhaustion,  not  associated  with  or  the  result  of  an 
infectious  disease,  is  the  chief  precipitating  cause  of  the  mental  dis- 
order, e.g.,  hemorrhage,  severe  physical  over-exertion,  deprivation  of 
food,  prolonged  insomnia,  debility  from  wasting  disease,  etc. 

Of  the  psychoses  which  occur  with  diseases  of  the  ductless  glands, 
the  best  known  are  the  thyroigenous  mental  disorders.  Disturbance 
of  the  pituitary  or  of  the  thymus  function  is  often  associated  with 
mental  symptoms. 

According  to  the  etiology  and  symptoms  the  following  types  should 
therefore  be  specified  under  "  Psychoses  with  other  Somatic  Diseases  ": 


DEFINITIONS  AND  EXPLANATORY  NOTES         635 

(a)  Delirium  with  infectious  disease  (specify). 
(6)  Post-infectious  psychoses  (specify) 

(c)  Exhaustion  dehrium. 

(d)  Delirium  of  unknown  origin. 

(e)  Cardio-renal  disease. 

(f)  Diseases  of  the  ductless  glands  (specify) . 

(g)  Other  diseases  or  conditions  (to  be  specified). 

13.  Manic-Depressive  Psychoses. — This  group  comprises  the 
essentially  benign  affective  psychoses:  mental  disorders  which  funda- 
mentally are  marked  by  emotional  oscillations  and  a  tendency  to  recur- 
rence. Various  psychotic  trends,  delusions,  illusions  and  hallucina- 
tions, clouded  states,  stupor,  etc.,  may  be  added.  To  be  distinguished 
are: 

The  manic  reaction  with  its  feeling  of  well-being  (or  irascibihty), 
flight  of  ideas  and  over-acti\dty. 

The  depressive  reaction  with  its  feeling  of  mental  and  physical  in- 
sufficiency, a  despondent,  sad  or  hopeless  mood  and  in  severe  depres- 
sions, retardation  and  inhibition;  in  some  cases  the  mood  is  one  of 
imeasiness  and  anxiety,  accompanied  by  restlessness. 

The  mixed  reaction,  a  combination  of  manic  and  depressive  symp- 
toms. 

The  stupor  reaction  with  its  marked  reduction  in  activity,  depres- 
sion, ideas  of  death,  and  often  dream-like  hallucinations;  sometimes 
mutism,  drooling  and  muscular  sjTnptoms  suggestive  of  the  catatonic 
manifestations  of  dementia  prsecox,  from  which,  however,  these  manic- 
depressive  stupors  are  to  be  differentiated. 

An  attack  is  caUed  circular  when,  as  is  often  the  case,  one  phase 
is  followed  immediately  by  another  phase,  e.g.,  a  manic  reaction  passes 
over  into  a  depressive  reaction  or  vice  versa. 

Cases  formerly  classed  as  "Allied  to  Manic-depressive  "  should  be 
placed  here  rather  than  in  the  "  Undiagnosed  "  group. 

In  the  statistical  reports  the  following  sho\iId  be  specified: 

(a)  Manic  attack. 

(6)  Depressive  attack. 

(c)  Stuporous  attack. 

(d)  Mixed  attack. 

(e)  Circular  attack. 

14.  Involution  Melancholia. — These  depressions  are  probably  re- 
lated to  the  manic-depressive  group;  nevertheless  the  symptoms  and 
the  course  of  the  involution  cases  are  sufficiently  characteristic  to 
justify  us  in  keeping  them  apart  as  special  forms  of  the  emotional 
reaction. 

To  be  included  here  are  the  slowly  developing  depressions  of  middle 
life  and  later  years  which  come  on  with   worry,  insomnia,  uneasiness 


636  OFFICIAL  CLASSIFICATION 

anxiety  and  agitation,  showing  usually  the  unreality  and  sensory  com- 
plex, but  Utile  or  no  evidence  of  any  difficulty  in  thinking.  The  tend- 
ency is  for  the  course  to  be  a  prolonged  one.  Arteriosclerotic  depres- 
sions should  be  excluded. 

When  agitated  depressions  of  the  involution  period  are  clearly 
superimposed  on  a  manic-depressive  foundation  with  previous  attack 
(depression  or  excitement)  they  should,  for  statistical  purposes,  be 
classed  in  the  manic-depressive  group. 

15.  Dement'.a  Praecox. — This  group  carmot  be  satisfactorily 
defined  at  the  present  time,  as  there  are  stiU  too  many  points  at  issue 
as  to  what  constitute  the  essential  clinical  features  of  dementia  prsecox. 
A  large  majority  of  the  cases  which  should  go  into  this  group  may, 
however,  be  recognized  without  special  difficulty,  although  there  is  an 
important  smaller  group  of  doubtful,  atypical,  allied  or  transitional 
cases  which  from  the  standpoint  of  symptoms  or  prognosis  occupy  an 
uncertain  clinical  position. 

The  term  "  schizophrenia  "  is  now  used  by  many  writers  instead 
of  dementia  prsecox.  Cases  formerly  classed  as  "Allied  to  Dementia 
Prsecox  "  should  be  placed  here  rather  than  in  the  "  Undiagnosed  " 
group. 

The  following  mentioned  features  are  sufficiently  well  established 
to  be  considered  most  characteristic  of  the  dementia  prsecox  type  of 
reaction : 

A  seclusive  type  of  personality  or  one  showing  other  evidences 
of  abnormality  in  the  development  of  the  instincts  and  feelings. 

Appearance  of  defects  of  interests  and  discrepancies  between 
thought  on  the  one  hand  and  the  behavior-emotional  reactions  on  the 
other. 

A  gradual  blunting  of  the  emotions,  growing  indifference  or  silliness 
with  serious  defects  of  judgment  and  often  hypochondriacal  com- 
plaints, suspicions  or  ideas  of  reference. 

Development  of  peculiar  trends,  often  fantastic  ideas,  with  odd, 
impulsive  or  negativistic  conduct  not  accounted  for  by  any  acute 
emotional  disturbance  or  impairment  of  the  sensorium. 

Appearance  of  autistic  thinking  and  dream-like  ideas,  peculiar 
feelings  of  being  forced,  of  interference  with  the  mind,  of  physical  or 
mystical  influences,  but  with  retention  of  clearness  m  other  fields 
(orientation,  memory,  etc.). 

According  to  the  prominence  of  certain  symptoms  in  individual 
cases  the  following  four  clinical  forms  of  dementia  prsecox  may  be 
specified,  but  it  should  be  borne  in  mind  that  these  are  only  relative 
distinctions  and  that  transitions  from  one  clinical  form  to  another  are 
common : 

(a)  Paranoid  type:   Cases  characterized  by  a  prominence  of  delu- 


DEFINITIONS  AND  EXPLANATORY  NOTES         637 

sions,  particularly  ideas  of  persecution  or  grandeur,  often  connectedly- 
elaborated,  with  hallucinations  in  various  fields. 

(6)  Catatonic  type:  Cases  in  which  there  is  a  prominence  of 
negativistic  reactions  or  various  peculiarities  of  conduct  with  phases 
of  stupor  or  excitement,  the  latter  characterized  by  impulsive,  queer  or 
stereotyped  behavior  and  usually  hallucinations. 

(c)  Hebephrenic  type:  Cases  showing  prominently  a  tendency  to 
siUrness,  smiling  and  laughing,  grimacing,  mannerisms  in  speech  and- 
action,  and  numerous  peculiar  ideas  usually  absurd,  grotesque  and 
changeable  in  form. 

(d)  Simple  type:  Cases  characterized  by  defects  of  interest,  gradual 
development  of  an  apathetic  state,  often  with  peculiar  behavior,  but 
without  expression  of  delusions  or  hallucinations. 

16.  Paranoia  and  Paranoic  Conditions. — From  this  group  should  be 
excluded  the  deteriorating  paranoic  states  and  paranoic  states  sympto- 
matic of  other  mental  disorders  or  of  some  damaging  factor  such  as 
alcohol,  organic  brain  disease,  etc. 

The  group  comprises  cases  which  show  clinically  fixed  suspicions, 
persecutory  delusions,  dominant  ideas  or  grandiose  trends  logically 
elaborated  and  with  due  regard  for  reaUty  after  once  a  false  interpre- 
tation or  premise  has  been  accepted.  Further  characteristics  are 
formally  correct  conduct,  adequate  emotional  reactions,  clearness 
and  coherence  of  the  train  of  thought. 

17.  Epileptic  Psychoses. — In  addition  to  the  epileptic  deterioration 
transitory  psychoses  may  occur  which  are  usually  characterized  by  a 
clouded  mental  state  followed  by  an  amnesia  for  external  occurrences 
diu-ing  the  attack.  (The  hallucinatory  and  dream-Uke  experiences  of 
the  patient  during  the  attack  may  be  vividly  recalled.)  Various 
automatic  and  secondary  states  of  consciousness  may  occur. 

According  to  the  most  prominent  clinical  features  the  epileptic 
mental  disorders  should  therefore  be  specified  as  foUows: 

(a)  Deterioration:  A  gradual  development  of  mental  dullness, 
slowness  of  association  and  thinking,  impairment  of  memory,  irritability 
or  apathy. 

(b)  Clouded  states.  Usually  in  the  form  of  dazed  reactions  with 
deep  confusion,  bewilderment  and  anxiety  or  excitements  with  halluci- 
nations, fears  and  violent  outbreaks;  instead  of  fear  there  may  be 
ecstatic  moods  with  reUgious  exaltation. 

(c)  Other  conditions.     (To  be  specified.) 

18.  Psychoneuroses  and  Neuroses. — The  psychoneurosis  group 
includes  those  disorders  in  which  mental  forces  or  ideas  of  which  the 
subject  is  either  aware  (conscious)  or  unaware  (subconscious)  bring 
about  various  mental  and  physical  symptoms — in  other  words  these 
disorders  are  essentially  psychogenic  in  nature. 


638  OFFICIAL  CLASSIFICATION 

The  term  "  neurosis  "  is  now  generally  used  synonymously  with 
psychoneurosis,  although  it  has  been  appUed  to  certain  disorders  in 
which,  while  the  symptoms  are  both  mental  and  physical,  the  primary 
cause  is  thought  to  be  essentially  physical.  In  most  instances,  how- 
ever, both  psychogenic  and  physical  causes  are  operative  and  we  can 
assign  only  a  relative  weight  to  the  one  or  the  other. 

The  following  types  are  sufficiently  weU  defined  clinically  to  be 
specified: 

(a)  Hysterical  type:  Episodic  mental  attacks  in  the  form  of  delirium, 
stupor  or  dream  states  during  which  repressed  wishes,  mental  conflicts 
or  emotional  experiences  detached  from  ordinary  consciousness  break 
through  and  temporarily  dominate  the  mind.  The  attack  is  followed 
by  partial  or  complete  amnesia.  Various  physical  disturbances  (sen- 
sory and  motor)  occur  in  hysteria,  and  these  represent  a  conversion  of 
the  affect  of  the  repressed  disturbing  complexes  into  bodily  symptoms 
or,  according  to  another  formulation,  there  is  a  dissociation  of  con- 
sciousness regarding  some  physical  function. 

(6)  Psychasthenic  type:  This  includes  also  the  compulsive  and 
obsessional  neuroses  of  some  writers.  The  main  clinical  characteristics 
are  phobias,  obsessions,  morbid  doubts  and  impulsions,  feelings  of  in- 
sufficiency, nervous  tension  and  anxiety.  Episodes  of  marked  depres- 
sion and  agitation  may  occur.  There  is  no  disturbance  of  conscious- 
ness or  amnesia  as  in  hysteria. 

(c)  Neurasthenic  type:  This  should  designate  the  fatigue  neuroses 
in  which  physical  as  well  as  mental  causes  evidently  figure;  character- 
ized essentially  by  mental  and  motor  fatigability  and  irritability;  also 
various  hypersesthesias,  parsesthesias,  hypochondriasis  and  varying 
degrees  of  depression. 

(d)  Anxiety  neuroses:  A  clinical  type  in  which  morbid  anxiety  or 
fear  is  the  most  prominent  feature.  A  general  nervous  irritability  (or 
excitability)  is  regularly  associated  with  the  anxious  expectation  or 
dread;  in  addition  there  are  numerous  physical  symptoms  which  may 
be  regarded  as  the  bodily  accompaniments  of  fear,  particularly  cardiac 
and  vasomotor  disturbances:  the  heart's  action  is  increased,  often 
there  is  irregularity  and  palpitation;  there  may  be  sweating,  nausea, 
vomiting,  diarrhoea,  suffocative  feelings,  dizziness,  trembling,  shaking, 
difficulty  in  locomotion,  etc.  Fluctuations  occur  in  the  intensity  of 
the  symptoms,  the  acute  exacerbations  constituting  the  "  anxiety 
attack." 

19.  Psychoses  with  Constitutional  Psychopathic  Inferiority. — 
Under  the  designation  of  constitutional  psychopathic  inferiority  is 
brought  together  a  large  group  of  pathological  personalities  whose 
abnormality  of  make-up  is  expressed  mainly  in  the  character  and 
intensity  of  their  emotional  and  volitional  reactions.     Individuals  with 


DEFINITIONS  AND  EXPLANATORY  NOTES  639 

an  intellectual  defect  (feeblemindedness)  are  not  to  be  included  in  this 
group. 

Several  of  the  preceding  groups,  in  fact  all  of  the  so-called  consti- 
tutional psychoses,  manic-depressive,  dementia  prsecox,  paranoia, 
psychoneuroses,  etc.,  may  be  considered  as  arising  on  a  basis  of  psycho- 
pathic inferiority  because  the  previous  mental  make-up  in  these  condi- 
tions shows  more  or  less  clearly  abnormalities  in  the  emotional  and 
Tolitional  spheres.  These  reactions  are  apparently  related  to  special 
forms  of  psychopathic  make-up  now  fairly  well  differentiated,  and 
the  associated  psychoses  also  have  their  own  distinctive  features. 

There  remain,  however,  various  other  less  well-differentiated  types 
of  psychopathic  personalities,  and  in  these  the  psychotic  reactions 
(psychoses)  also  differ  from  those  already  specified  in  the  preceding 
groups. 

It  is  these  less  well-differentiated  types  of  emotional  and  volitional 
deviation  which  are  to  be  designated,  at  least  for  statistical  purposes, 
as  constitutional  psychopathic  inferiority.  The  type  of  behavior 
disorder,  the  social  reactions,  the  trends  of  interests,  etc.,  which  the 
psychopathic  inferior  shows  give  special  features  to  many  cases,  e.g., 
criminal  traits,  moral  deficiency,  tramp  life,  sexual  perversions  and 
various  temperamental  peculiarities. 

The  pronounced  mental  disturbances  or  psychoses  which  develop 
in  psychopathic  inferiors  and  bring  about  their  commitment  are  varied 
in  their  clinical  form  and  are  usually  of  an  episodic  character.  Most 
frequent  are  attacks  of  irritability,  excitement,  depression,  paranoid 
episodes,  transient  confused  states,  etc.  True  prison  psychoses  belong 
in  this  group. 

In  accordance  with  the  standpoint  developed  above,  a  psychopathic 
inferior  with  a  manic-depressive  attack  should  be  classed  in  the  manic- 
depressive  group,  and  likewise  a  psychopathic  inferior  with  a  schizo- 
phrenic psychosis  would  go  into  the  dementia  praecox  group. 

Psychopathic  inferiors  without  an  episodic  mental  attack  or  any 
psychotic  symptoms  should  be  placed  in  the  "Not  Insane"  group  under 
the  appropriate  sub-heading. 

20.  Psychoses  with  Mental  Deficiency. — This  group  includes  the 
various  types  of  intellectual  deficiency  or  feeblemindedness.  The  degree 
of  mental  deficiency  should  be  determined  by  the  history  and  the  use  of 
standard  psychometric  tests.  The  intellectual  level  may  be  denoted 
in  the  statistics  by  specifying  moron,  imbecile,  idiot. 

Acute,  usually  transient,  psychoses  of  various  forms  occur  in  men- 
tally deficient  persons  and  commitment  to  a  hospital  for  the  insane 
may  be  necessary.  The  most  common  mental  disturbances  are  episodes 
of  excitement  or  irritabihty,  depressions,  paranoid  trends,  hallucina- 
tory attacks,  etc. 


640  OFFICIAL  CLASSIFICATION 

Mentally  deficient  persons  may  suffer  from  manic-depressive 
attacks  or  from  dementia  prsecox.  When  this  occurs  the  diagnostic 
grouping  should  be  manic-depressive  or  dementia  praecox  as  the  case 
may  be. 

Mental  deficiency  cases  without  psychotic  disturbances  should  go 
into  the  group  of  "  Not  Insane  "  under  the  appropriate  sub-heading. 

21.  Undiagnosed  Psychoses. — In  this  group  should  be  included  cases 
in  which  a  satisfactory  diagnosis  cannot  be  made  and  the  psychosis 
must  therefore  be  regarded  as  an  unclassified  one.  The  difficulty 
may  be  due  to  lack  of  information  or  inaccessibility  of  the  patient; 
or  the  clinical  picture  may  be  obscure,  the  etiology  unknown,  or  the 
symptoms  unusual.  Cases  placed  in  this  group  during  the  year  should 
be  again  reviewed  before  the  annual  diagnostic  tables  are  completed. 

Cases  of  the  type  formerly  placed  in  one  of  the  allied  groups  should 
not  be  put  in  the  undiagnosed  group  except  for  some  special  reason. 
Most  of  the  cases  hitherto  called  allied  should  be  placed  in  the  main 
group  to  which  they  seem  most  closely  related. 

22.  Not  Insane. — This  group  should  receive  the  occasional  case 
which  after  investigation  and  observation  gives  no  evidence  of  having 
had  a  psychosis.  The  only  difficulty  likely  to  be  encountered  in  the 
statistical  reports  will  arise  in  the  grouping  of  patients  who  have  recov- 
ered from  a  psychosis  prior  to  admission.  In  such  cases,  if  the  history, 
the  commitment  papers  or  the  patient's  retrospective-  account  show 
that  a  psychosis  actually  existed  immediately  before  admission,  that  is, 
at  the  time  of  commitment,  then  the  case  should  be  considered  as  having 
suffered  from  a  mental  disorder,  and  classification  under  the  appropriate 
heading  should  be  made. 

If  it  is  determined  that  no  psychosis  existed,  then  the  condition 
which  led  to  admission  should  be  specified.  The  following  come 
most  frequently  into  consideration: 

(a)  Epilepsy  without  psychosis. 

(6)  Alcoholism  without  psychosis. 

(c)  Drug  addiction  without  psychosis. 

(d)  Constitutional  psychopathic  inferiority  without  psychosis. 

(e)  Mental  deficiency  without  psychosis. 
(/)  Other  conditions  (to  be  specified), 


INDEX  OF  AUTHORS 


Adler,  H.  M.,  148. 

Alzheimer,  A.,  261,  392,  405,  407, 

443,  629. 
Amsden,  G.  S.,  79,  402. 
Angiolella,  D.,  395. 
Anglade,  J.,  392. 
Antheaume,  A.,  341. 
Amaud,  48,  56,  319,  378,  385. 
Aschaffenbiirg,  G.,  7,  90,  174,  260, 

421. 

Babinski,  J.,  302,  303,  310,  311, 

338,  366,  382,  388,  441. 
Baer,  A.,  176 
Bailey,  Pearce,  309. 
Baillarger,  J.,  53,  108,  370. 
Baillet,  376. 
Balint,  R.,  444. 
Ball,  C.  R.,  22,  103. 
BaUet,  G.,  262,  371,  392,  423,  427. 
Barker,  L.  F.,  148. 
Basedow,  435. 
Baumann,  W.,  433. 
Bayle,  370. 
Beaunis,  H.,  36. 
Bechterew,  W.  v.,  33. 
Beers,  C.  W.,  115. 
Bergonie,  I.,  385. 
Bernard,  Claude,  63. 
Bernstein,  C,  204. 
Berze,  260. 
Besson,  A.,  207. 
Betz,  440. 
Binet,  A.,  88,  90,  91,  96,  169,  185, 

199. 


Binswanger,    O.,    302,   405,   409, 

427. 
Birnbaum,  K.,  11. 
Bleuler,  E.,  139,  220,  260. 
Bloch,  A.,  376. 
Bonnat,  385. 
Bordet,  J.,  461. 
Bordoni-Uffreduzzi,  64. 
Bouchard,  C,  371,  423,  430. 
Bourneville,  M.,  195,  435. 
Bramwell,  M.,  52. 
Brault,  J.,  430. 
Breuer,  302. 
Bridges,  J.  W.,  96. 
Brill,  A.  A.,  10,  120,  121,  124,  125, 

127,  138,  145,  301. 
Briquet,  433. 

Brissaud,  E.,  65,  371,  423,  429. 
BrowTi,  Mabel  W.,  311. 
Browning,  C.  H.,  396. 
Bruce,  A.  N.,  307. 
Brush,  N.  H.,  402,  455. 
Busch,  Max,  29. 

Calmiel,  J.  L.  F.,  370. 
Campbell,  C.  M.,  149. 
Campbell,  H.,  310. 
Capeletti,  213. 
Capgras,  J.,  292. 
Capps,  378. 
Carrier,  321. 
Casamajor,  L.,  196. 
Castin,  P.,  56. 
Chambard,  358. 
Chapin,  F.  S.,  150. 


641 


642 


INDEX  OF  AUTHORS 


Charcot,  J.  M.,  36,  86,  301,  371, 

395,  407,  423,  430. 
Chaslin,  P.,  422. 
Chenais,  234. 
Christian,  379. 
Church,  A.,  474. 
ColoUan,  38. 

Corson,  CaroUne  C,  301. 
Cotard,  J.,  56. 
Cotton,  H.  A.,  402,  439. 
Coulon,  371. 
CuUerre,  A.,  428,  429. 

Dagonet,  H.,  380. 

Dara'in,  C,  63,  125. 

Davenport,  C.  B.,  2,  3,  77,  192, 

212,  227,  285,  328,  329. 
Debove,  36,  86,  106,  107. 
Dejerine,  J.,  395. 
Delarras,  265. 
Delasiauve,  422. 
Delaye,  370. 
Delbriick,  A.,  47. 
DeQumcey,  T.,  358. 
Dercum,  F.  X.,  113,  114,  214,  308. 
Desvaux,  419. 
Devaux,  437. 
Dide,  M.,  234. 
Drej-fus,  G.  L.,  293,  298. 
Dubois,  Paul,  113,  117. 
Dumas,  G.,  63,  64,  65,  67,  269. 
Dunlap,  C.  B.,  396. 
Dupouy,  R.,  227. 
Dupre,  E.,  388,  437. 

Eastman,  F.  C,  547. 
Elderton,  Ethel  M.,  196. 
Ellis,  A.  W.  M.,  402. 
Erlenmeyer,  361. 
Esmarch,  395. 
Esquirol,  J.  E.  D.,  21. 
Exner,  S.,  393. 

Fagan,  J.  O.,  179. 
Fahet,  J.,  249,  254,  370. 


Farnarier,  29,  103. 

Faure,  M.,  427. 

Felton,  455,  457. 

Fere,  C,  205,  206,  207,  208,  331, 
339. 

Fernald,  G.  G.,  523. 

Femald,  W.  E.,  203,  204. 

Ferrari,  M.,  108, 

Fischer,  396. 

Fiske,  C.  N.,  178. 

Fordyce,  J.  H.,  365. 

Fournier,  A.,  168,  178,  396. 

Franz,  S.  I.,  91. 

Freud,  S.,  117,  121,  124,  125,  127, 
128,  129,  131,  137,  138, 141,  145, 
301,  302,  314,  315,  320,  323. 

Frink,  H.  W.,  145. 

Froment,  302. 

Fuchs,  A.,  452,  453,  454. 

Fuhrmann,  M.,  81. 

Fuller,  S.  C,  444. 

Furbush,  E.  M.,  212. 

Gamier,  C,  333. 

Gaster,  M.,  227. 

Gates,  M.  F.,  178. 

Gatian  de  Clerambault,  383. 

Gaupp,  R.,  305. 

Gengou,  O.,  461. 

Gcorget,  422. 

Glueck,  B.,  220,  310. 

Goddard,  H.  H.,  3,  185. 

Gourin,  106,  107. 

Gowers,  W.  R.,  394,  405. 

Graves,  435. 

Gray,  H.,  407. 

Grehiere.  384. 

Griesinger,  W.,  1,  22,  66,  103,  113, 

292,  434. 
Guislain,  103. 

Hamilton,  A.  S.,  328. 
Hammers,  455. 
Hardwick,  Rose  S.,  96. 
Harrison,  L.  W.,  178. 


INDEX  OF  AUTHORS 


643 


Haslam,  J.,  370. 
Healy,  M.  T.,  221. 
Healy,  W.,  221,  477,  -523. 
Hecker,  229. 

HeUbronner,  K.,  54,  211. 
Hellsten,  7. 
Heron,  D.,  167. 
Herz,  M.,  346,  347,  430. 
Hinkle,  Beatrice  M.,  137. 
Hippocrates,  2. 
Hitschmann,  E.,  145. 
Hoch,  August,  10,  79,  259,  285. 
Hoffding,  73. 
Hollingworth,  H.  L.,  iii. 
Huntington,  G.,  11,  78,  193,  327, 
625,  631. 

Jacob,  225. 

Jacquin,  428. 

Janet,  P.,  49,  301,  319. 

Jarrett,  Mary  C,  iii,  150. 

Jelliffe,  S.  E.,  113,  117,  120,  141, 

196,  301. 
Jendrassic,  81. 
Jessen,  395. 
Joffroy,  A.,  30,  34,  38,  85,  86,  227, 

321,  341,  347,  362,  384,  388,  395. 
Jolly,  P.,  256. 
Jones,  A.  B.,  309,  314. 
Jones,  E.,  120,  125,  141,  145,  313, 

391,  452,  459. 
Jouet,  360. 
Jung,  C.  G.,  10,  90,  120,  137,  141, 

145. 

Kahlbaum,  29,  229. 

Kaplan,  D.  M.,  368,  391,  455,  459, 

464. 
Kaufmann,  307,  311. 
Kellogg,  T.  H.,  147. 
Kent,  Grace  H.,  90,  98,  547,  551, 

552. 
Keraval,  P.,  52. 
Kirby,  G.  H.,  12,  194,  260,  350, 

628. 


Kirn,  29. 

Kline,  G.  M.,  149. 

Klippel,  M.,  339,  346,  347,  371, 
378,  385,  395,  419. 

Klopp,  H.  I.,  444. 

Koeppen,  M.,  47,  416 

Koester,  W.,  86. 

Kohn,  289. 

Korsakoff,  351,  626,  628,  629,  632, 
633. 

Kraepelin,  E.,  7,  67,  72,  90,  113, 
159,  174,  229,  234,  248,  254,  255, 
256,  260,  267,  281,  285,  286,  287, 
289,  292,  293,  332,  339,  371,  396, 
400,  412,  421,  428,  447. 

Krafft-Ebing,  R.  v.,  211,  223,  225, 
380,  395,  400. 

Krishaber,  36. 

Kuerz,  E.,  7,  174. 

Lambert,  C.  I.,  396,  405,  439. 

Lange,  C.,  63,  391,  452,  455. 

Laquer,  B.,  176. 

Lasegue,  342,  370. 

Lavoit,  89,  449. 

Leahy,  S.  R.,  357. 

Legay,  30. 

Legrande  du  Saulle,  206,  389. 

Leri,  A.,  304,  306. 

Leroy,  262. 

Levinstein,  O.,  361. 

Liepmann,  H.,  30,  344. 

Llewellyn,  L.  J.,  309,  314. 

Londe,  P.,  320. 

Lopez,  419. 

Lowell,  F.,  548. 

Lueckerath,  351. 

Lunier,  370. 

Lust,  F.,  305. 

Macdonald,  C,  313. 

Magnan,  V.,  103,  108,  206,  210, 

226,  248,  254,  262,  265,  321,  370, 

375,  399. 
Mahaim,  393,  394. 


644 


INDEX  OF  AUTHORS 


Mairet,  A.,  370. 

Manaud,  320. 

Mann,  368,  391. 

Marandon  de  Montyel,  53,  382. 

Marchi,  439. 

Marey,  64. 

Mariani,  C.  E.,  30. 

Marie,  P.,  382. 

Marinesco,  G.,  334. 

Marshall,  C.  F.,  168,  178. 

Masselon,  230,  233. 

Mayer,  M.,  7,  174. 

Mayo,  C.  H.,  436. 

McClelland,  455. 

McCrae,  301. 

McKenzie,  I.,  396. 

Mendel,  E.,  370. 

Mendel,  G.,  3. 

Mercklin,  105. 

Merson,  J.,  213. 

Meunier,  E.,  227. 

Meyer,  Adolf,  10,  153,  171,  256, 

257,  259,  260,  416,  439,  440,  470, 

633. 
Meyerson,  A.,  260. 
Meynert,  T.,  38. 
Mignot,  R.,  376. 
Miller,  455. 
Minet,  J.,  89,  449. 
Mitchell,  Ida,  547. 
Moebius,  P.  J.,  301,  302,  396. 
Moeli,  210. 
Moll,  Albert,  224. 
Moore,  Anne,  187. 
Moore,  A.  S.,  260. 
Moore,  J.,  371,  396,  398,  459. 
Morselli,  64. 
Mott,  F.  W.,  367. 
Mueller,  Johannes,  19,  23,  24,  38. 
Muncey,  E.  B.,  328. 
Murphy,  J.  K.,  178,  367. 

Nageotte,  I.,  394. 
Neilson,  W.  A.,  150. 
Neymann,  C.  A.,  iii,  402. 


Nissl,  393,  427,  444. 
Noguchi,  H.,  89,  391,  396,  398, 
452,  459,  465. 

Ogilvie,  H.  S.,  402. 
Ordway,  Mabel,  213. 
Ormea,  A.  d',  213. 
Orr,  Florence  I.,  3,  6,  255. 
Orton,  S,.  T.,  261. 
Osier,  W.,  301. 
Otis,  Margaret,  547. 

Pal,  393. 

Pandy,  89,  391,  452,  459. 

Parchappe,  370. 

Paton,  S.,  474.  ^ 

PajTie,  C.  R.,  120,  145,  314. 

Pearson,  Karl,  196. 

Perusini,  G.,  444. 

Peterson,  F.,  10,  145,  314. 

Petri,  462. 

Pfister,  109 

Pfister,  O.,  120,  314. 

Pichon,  360. 

Pick,  54,  56. 

Pierracini,  37. 

Pierret,  385. 

PUcz,  A.,  233. 

Pitres,  A.,  320,  323. 

Plant,  F.,  196,  396. 

Pochon,  103. 

PoUock,  H.  M.,  17,  212. 

Pollock,  L.  J.,  441. 

Power,  D'Arcy,  178,  367. 

Preyer,  474. 

Proos,  433. 

Putnam,  J.  P.,  147. 

Rauschburg,  P.,  444. 
Regis,  E.,  211,  320,  323,  448. 
Reiss,  E.,  285. 
Revington,  G.,  26. 
Ribot,  T.,  45,  47,  75,  320. 
Richet,  213. 
Ritti,  A.,  379,  448. 


INDEX  OF  AUTHORS 


645 


Robertson,  A.,  366,  377,  388. 

Rogues  de  Fursac,  J.,  iii,  86,  357, 
371. 

Romberg,  81. 

Rosanoff,  A.  J.,  m,  3,  6,  10,  11,  15, 
18,  90,  98,  148,  160,  165,  171, 
173,  174,  185,  190,  213,  218,  255, 
260,  261,  303,  396,  459,  547,  551, 
552. 

Rosanoff,  Isabel  R.,  547. 

Rosenthal,  452,  453,  454. 

Ross,  G.  W.,  391,  452,  459. 

Roubinowitch,  J.,  262,  319. 

Riiedin,  E.,  29,  255,  332. 

Russell,  W.  L.,  443. 

Ryon,  W.  G.,  329. 

Ryther,  Margherita,  213. 

Sadras,  370. 

Samt,  207,  210. 

Sander,  60,  262. 

Saury,  H.,  363. 

Schneider,  L.,  7,  174. 

Schtile,  65. 

Schultze,  Otto,  307. 

Schwartz,  211. 

Seglas,  J.,  31,  36,  37,  38,  53,  56,  57, 

58,  86,  262,  296,  320,  422,  423. 
Serieux,  P.,  38,  103,  104,  233,  341, 

370. 
Serveaux,  65,  341,  378. 
Sheehan,  R.,  310. 
Shields,  434. 
Sicard,  J.  A.,  311. 
Siebert,  38. 

Simon,  T.,  88,  90,  91,  96,  199. 
Simon,  T.  W.,  260. 
Singer,  H.  D.,  441. 
Sioh,  261. 
Smith,  A.,  7,  174. 
Snydacker,  E.  F.,  399. 
Sollier,  P.,  196,  362. 
Somers,  E.  M.,  439. 
Sommer,  R.,  49,  81,  206. 
Sophocles,  132. 


Southard,  E.  E.,   149,   150,   156, 

261,  439. 
Spaulding,  Edith  R.,  150. 
Steen,  R.  H.,  11. 
Stier,  E.,  227. 
Stoddart,  W.  H.  B.,  238. 
Strieker,  37. 
Strong,  E.  K.,  Jr.,  547. 
Swalm,  368,  391. 
Swift,  H.  F.,  402. 
Sydenham,  632. 

Tambourini,  A.,  38. 
Terman,  L.  M.,  96,  198,  476. 
Thivet,  31,  448. 
Tiffany,  W.  J.,  444. 
Toulouse,  E.,  213. 
Trabue,  M.  R.,  621. 
Trenel,  M.,  56. 
Treves,  M.,  384. 
Tschisch,  W.,  237. 
Tuczek,  393. 
Turner,  J.,  439. 

Uhland,  134. 

Vallon,  C,  38,  211,  225,  321,  322, 

382. 
Viallon,  107. 
Vignaud,  370. 
Vu-es,  370. 
Voisin,  A.,  206,  370. 

Wardner,  D.  M.,  402. 
Wassermann,  A.,  89,  178,  364,  367, 

391,  396,  401,  411,  438,  451,  452, 

460,  469,  630. 
Weeks,  D.  F.,  3,  212. 
Weigandt,  W.,  267. 
Weigert,  C.,  393. 
Wells,  F.  L.,  91,  138,  547. 
Wernicke,  C.,  24,  31,  32,  33,  39, 

40,  52,  53,  73,  74,  269,  270,  342, 

344,  347,  379,  447. 
Westphal,  A.,  233,  319. 


646 


INDEX  OF  AUTHORS 


Whipple,  G.  M.,  91. 

White,  W.  A.,  113,  117,  182,  302. 

Wiglesworth,  J.,  438. 

Wilhams,  F.  E.,  311. 

WUUs,  T.,  405,  407. 

Wiseman,  J.  I.,  396,  459. 

Wizel,  103. 

Woodrcw,  H.,  548. 


Woodworth,  R.  S.,  91,  547. 
Worcester,  W.  L.,  439. 

Yerkes,  R.  M.,  96. 
Young,  H.  H.,  364. 

Ziehen,  T.,  287. 


INDEX  OF   SUBJECTS 


Abortion,  10. 

Aboulia,  41,  63,  66,  70,  73,  277, 

278,  359,  422,  427,  431. 
Abscess  of  the  brain,  437,  433. 
Absence,  42,  207. 
Absent-mindedness,  328. 
Absinthe,  337,  352. 
Abstinence,  10,  170,  174,  175,  213, 

289,  341,  342,  346,  347,  334, 

412. 
Abstinence,  pledge  of,  114. 
Abstinence,    symptoms    of,    347, 

356,  360,  361. 
Absurdity,    352,    374,    414,    630, 
631. 

See  also  Delusions,  absurd. 
Abuse  by  husband,  11. 
Accessibility  of  institutions,  15. 
Acute   hallucinosis,    7,    194,    252, 

342,  348-350,  626,  632. 
Addiction    to    drugs,    see    Drug 

addictions. 
Admission  of  patients,  102. 
Adult  sexuality,  122. 
Esthetic  morality,  316,  317. 
^Esthetic  sense,  122. 
Affect,  120,  140,  301,  302,  638. 
Affect,  displacement  of,  129,  135, 

136. 
Affect  in  dreams,  132,  137. 
Affection,  140. 
Affectivity,  25,  26,  28,  41,  55,  57, 

58,  61-70,  74,  97,  182,  207, 

219,  229,  230,  231,  232,  236, 

239,  246,  248,  251,  255,  256, 

268,  277,  286,  291,  335,  353, 


359,  371,  373,  380,  425,  429, 
435,  445,  447,  631,  632,  635. 

After-care,  77,  117-119,  154. 

Age,  1,  13,  14,  16,  17,  95,  98,  139, 
248,  255,  262,  285,  290,  292, 
328,  329,  331,  357,  368,  400, 
411,  431,  441,  443,  474,  553, 
621. 

Age,  chronological,  95. 

Age,  mental,  95,  197,  198,  480. 

Aggressive  tendencies,  349,  414. 

Agitated  melancholia,  292. 

Agitation,  25,  66,  208,  281,  292, 
295,  298,  299,  324,  333,  344, 
348,  351,  352,  361,  411,  419, 
426,  429,  430,  441,  625,  629, 
636,  638. 

Agoraphobia,  323. 

Akoasms,  31. 

Albuminuria,  294,  298,  345,  350, 
331,  378,  385,  423,  430. 

Alcohol,  2,  7,  9,  10,  14,  77,  79,  165, 
169,  175,  211,  215,  216,  270, 
289,  321,  347,  348,  355,  421, 
637. 

Alcoholic  delusional  states,  7,  38, 
194,  260,  266,  336,  342,  350, 
626,  633. 

Alcoholic  dementia,  7,  194,  338, 
350,  443,  447,  448,  626,  633. 

Alcoholic  hallucinosis,  see  Acute 
hallucinosis. 

Alcoholic  psychoses,  7,  10,  12,  14, 
15,  16,  30,  88,  108,  119,  159, 
166,  192,  194,  363,  391,  626, 
632. 


647 


648 


INDEX  OF  SUBJECTS 


Alcoholism,  acute,  331-334. 
Alcoholism,  chronic,  7,  170,  172- 
177,  211,  252,  296,  303,  331, 
333,  335-354,  394,  399,  443, 
627,  632,  640. 
diagnosis,  338. 
episodic  accidents,  342-354. 
etiology,  339-341. 
pathological  anatomy,  338-339. 
physical  symptoms,  337-338. 
prognosis,  338. 
prophylaxis,  174. 
psychic  symptoms,  335. 
treatment,  341. 
Alcoholism,  parental,  195,  196. 
Alienation,  mental,  xiv,  52. 
Allied  to   dementia  prsecox  psy- 
choses, 100,  260,  636. 
Allied   to    manic-depressive   psy- 
choses, 100,  260,  318,|319,635. 
Allopsychic  orientation,  see  Orien- 
tation, allopsychic. 
Almshouse,  78,  204,  212. 
Alternating  psychoses,  283,  288. 
Altruism,  61. 

Alzheimer's  disease,  443,  629. 
Amaurosis,  300,  309,  366,  383. 
Ambition,  53,  216,  235. 
Amblyopia,  309,  383. 
Amboceptor,  460,  463-465. 
American      Medico-Psychological 

Association,  194,  625. 
Ammonium  sulphate  test,   Ross- 
Jones,  89,  391,  459. 
Amnesia,    42-46,    208,   300,    333, 

351,  352,  354,  374,  415,  416, 
632,  637,  638. 

anterograde,  43,  46,  231,  335, 

352,  372,  431,  444. 
course  of,  44,  45,  335. 
general,  46. 

law  of,  45,  335,  352,  373,  445. 
of  conservation,  43,  44,  445. 
of  fixation,  43,  44,  231,  352,  372, 
415,  431,  444. 


Amnesia  of  reproduction,  44,  46, 
352,  359,  431. 
partial,  46. 

progressive,  44,  45,  46,  335. 
retrograde,  43,  44,  46,  231,  335, 

352,  359,  373,  431,  445. 
retrogressive,  44. 
stationary,  44. 
varieties  of,  46. 

Amorous  paranoiacs,  265. 

Anaesthesia,  68,  108,  233,  300,  303, 
307,  309,  344,  366,  382,  410, 
411. 

Analgesia,  309. 

Anamnesis,  see  History  taking. 

Anatomical  stigmata  of  degenera- 
tion, 197. 

Anatomy,  pathological,  see  Patho- 
logical anatomy. 

Anemia,  91. 

Aneurism,  399,  408,  410. 

Anger,  25,  61,  67,  68,  205,  219,  231, 
269,  336,  371,  374,  387,  389, 
416,  445. 

Ankle  clonus,  81. 

Anorexia,  234,  235,  277,  279,  292, 
294,  338,  385,  422.  See  also 
Appetite. 

Antagonism,  automatic,  72. 

Anterior  cerebral  artery,  409. 

Anterograde  amnesia,  see  Amne- 
sia, anterograde. 

Antibodies,  461. 

Antigen,  461,  465-467. 

Antisocial  behavior,  xiv,  78, 79, 200. 

Anuria,  430. 

Anxiety,  25,  41,  65,  66,  130,  134, 
207,  208,  231,  243,  245,  278, 
292,  294,  295,  296,  298,  319, 
320,  323,  324,  325,  351,  361, 
408,  435,  441,  447,  627,  629, 
635,  636,  637,  638. 

Anxiety  neurosis,  627,  638. 

Anxious  melancholia,  292,  295, 
296,  298. 


INDEX  OF  SUBJECTS 


649 


Apathy,  81,  205,  239,  240,  473, 

631,  637. 
Aphasia,  46,  367,  385,  409,  418, 
438,  447,  628,  629. 
examination  for,   81,   90,   470- 

473. 
motor,  382,  409. 
sensory,  409. 
Aphonia,  121,  300,  307,  309,  409. 
Apoplectiform  seizures,  337,  375, 
379,  382,  383,  386,  390,  408, 
410,  447. 
Apoplexy,  385,  410,  412,  448. 
Appendix    to    frequency    tables, 

603-620. 
Apperception,  199. 
Appetite,  64,  79,  80,  233.  271,  297, 

318,  423,  446. 
Apprehensiveness,  67,  82,  441. 
Apraxia,  438,  473,  629. 
Arabs,  13. 

Arachnitis,  chronic,  370. 
Arcus  senilis,  446. 
Argumentativeness,  218. 
Argyll-Robertson  pupils,  366,  377, 

388. 
Arithmomania,  321. 
Army    neuro-psychiatric    experi- 
ences, 8,  303-317. 
Army  post,  192. 

Arrests  of  development,  xiii,  6,  11, 
77,   193,    195-214,   260,   327, 
433.     See   also   Feeble-mind- 
edness  and  Mental  deficiency, 
complications,  200. 
diagnosis,  201. 
early  manifestations,  196. 
etiology,  195. 
prognosis,  202. 
symptoms,  197. 
treatment,  202. 
Arsenical  poisoning,  626,  633. 
Arson,  187. 

Arterial  supply  of  the  brain,  405, 
406. 


Arterio-capillary  fibrosis,  408. 

Arteriosclerosis,  399,  446,  633. 

Arteriosclerosis,  cerebral,  see  Cere- 
bral arteriosclerosis. 

Artistic  activities,  124. 

Assault,   32,   219,  247,  250,   273, 
336. 

Association  of  ideas,  20,  21,  48-54, 
68,  69,  70,  85,  199,  229,  230, 
231,  232,  252,  268,  277,  281, 
286,  287,  293,  332,  359,  373, 
374,  422,  431,  444,  475,  637. 
automatic,  49,  70,  287. 
voluntary,  49,  70,  287. 

Association  tests,  90,  97,  98,  141, 
547-620. 

Assonance,  50. 

Astereognosis,  409. 

Asthma,  78. 

Asylums,  78,  186,  220. 

Atavistic  heredity,  2,  328. 

Ataxia,  86,  388. 

Atheroma,  338,  341,  385,  448. 

Atony,  muscular,  318. 

Atrophy,  brain,  261,  330,  391,  392, 
407,  408,  410,  411,  448. 

Atrophy,     muscular,     300,     374, 
384. 

Atrophy,  optic,  360,  383. 

Attacks,  previous,  80,  273. 

Attention,  22,  28,  30,  49,  85,  141, 
230,  231,  232,  268,  273,  291, 
359,  373,  415,  416,  417,  418, 
422,  431,  444,  470,  474,  550, 
628,  629. 
abnormal  mobility  of,  48,  50. 
deliberate,  48,  49. 
paralysis  of,  48. 
spontaneous,  48. 
voluntary,  48,  49. 
weakening  of  49,  50,  51,  231, 
253,  277,  286,  287,  290. 

Attitudes,  stereotypy  of,  72,  232, 
238,  242. 

Aura,  epileptic,  81,  206. 


650 


INDEX  OF  SUBJECTS 


Authority,  parental,  124. 

Autistic  personality,  see  Per- 
sonality, autistic  or  shut- 
in. 

Autistic  thinking,  137-139,  636. 

Autochthonous  ideas,  see  Ideas, 
autochthonous. 

Auto-critical  faculty,  47,  84,  199, 
366. 

Auto-erotic  manifestations,  121. 

Auto-intoxication,  256,  281,  346, 
347,  396,  429,  431. 

Automatic  antagonism,  72. 

Automatic  reactions,  see  Reac- 
tions, automatic. 

Automatic  writing,  37. 

Automatism,  epileptic,  207,  637. 

Automatism,  mental,  38,  42,  50, 
51,  52,  53,  70,  85,  236,  237, 
238,  251,  258,  268,  286,  287, 
288,  319,  332,  333,  422,  424, 
425,  426,  429,  444. 

Automatism,  negative,  72,  73. 

Autopsy,  38,  39,  367,  368, 396,  399, 
405,  409,  439,  629.  See  also 
Pathological  anatomy. 

Autopsychic  orientation,  see  Ori- 
entation, autopsychic. 

Auto-suggestion,  312. 

Auto-toxic  psychoses,  194. 

Average,  93. 

Awareness,  120. 

Axonal  alteration,  439. 

Babinski  sign,  81,  366,  382,  388, 

441. 
Background  thoughts,  143. 
Bacteriolysis,  461. 
Balancing  power,  81. 
Basal  nuclei,  410. 
Bashfulness,  319. 
Baths,  cold,  421. 
Baths,  continuous,  see  Continuous 

baths. 
Bed-sores,  384,  402. 


Begging,  228 

Behavior,  antisocial,  see  Antisocial 

behavior. 
Belladonna,  436. 
Benevolence,  387. 
Bestiality,  224,  225. 
Bewilderment,  424,  634,  637. 
Bhang,  355,  356. 
Bias  of  judgment,  183,  218. 
Binet-Simon  tests,  88,  90,  91,  96, 
169,  185. 

Stanford  revision,  96,  198,  476- 
546. 
Blocking,  73. 
Blood  changes,  378,  396. 
Blood  letting,  430. 
Blood  pressure,  64,  69,  81,  295, 

361,  408,  428,  630. 
Blood  tests,  80,  89,  367,  401,  438. 
Blood  vessels,  392,  393,  394. 
Blues,  78,  79. 
Blushing,  323. 
Boarding  out,  202,  204. 
Bones,  abnormal  fragility  of,  383. 
Borderline   conditions,    100,    195, 

198. 
Bordet-Gengou  phenomenon,  461, 

462. 
Boulimia,  234,  385. 
Bowels,  condition  of,  80,  412. 
Brachial  paralysis,  409. 
Brachycephaly,  197 
Brain  abscess,  437,  438. 
Brain  atrophy,  see  Atrophy,  brain. 
Brain  tumor,  xiv,  38,  89,  367,  386, 
391,  437-438,  449,  458,  625, 
631. 
Brain  weight,  261,  392,  448. 
Bribery,  359. 
Bringing  up,  79,  122,  179, 
Bromides,  626,  633. 

in  delirium  tremens,  348 

in  epilepsy,  213,  214. 

in  excitement,  106. 

in  general  paralysis,  404. 


INDEX  OF  SUBJECTS 


651 


Bromides  in  hyperthyroidism,  436. 
in  manic-depressive  psychoses, 
289,  290 

Brocho-pneumonia,  see  Pneumo- 
nia. 

Business  troubles,  10,  79. 

Butyric  acid  test,  Noguchi's,  89, 
391,  459. 

Cachexia,  69,  251,  353,  354,  427, 
433,  435, 
in  general  paralysis,  374,  385, 

389. 
in  involutional  melancholia,  298. 
in  morphinism,  361,  362. 
in  senile  dementia,  448. 
Caffein,  214,  334,  348,  362. 
Calculating  ability,  200. 
Calligraphic  disorders,  85. 
Cancelling  A  test,  621,  623. 
Capacity  for  work,  see  Work,  ca- 
pacity for. 
Capacity  of  institutions,  173. 
Cardio-vascular  disorders,  64,  67, 

69,  385,  423,  430,  446,  635. 
Career,  179,  221. 
Case  history,  see  History. 
Catalepsy,  71,  239,  241,  280,  374, 

426,  429 
Catatonia,  41,  71,  82,   108,   109, 
110,  229,  230,  233,  236-243, 
244,  253,  254,  286,  635. 
Catatonic  excitement,   211,   236- 

243,  254,  290,  637. 
Catatonic  stupor,  233,  234,  236- 

243,  252,  254,  637. 
Catharsis,  psychic,  145. 
Causes,    1,    80,    195.      See    also 
Etiology, 
avoidable,  119. 
contributing,  1,  2,  7,  9,  10,  11, 

80,  165,  179,  628. 
essential,  1,   8,  9,  10,    11,   165, 

255,  285,  292,  413. 
exciting.  118.  399. 


Causes,  incidental,  1,  2,  7,  9,  10, 
11,  80,  165,  179,  628. 
physical,  10,  78,  303,  304. 
psychic,  10,  303,  304. 
Cell  count,  89,  364,  449,  452-454. 
Censor,    psychic,    128,    130,    131, 

136,  138. 
Central    neuritis,    437,    438-442, 

633. 
Central  scotoma,  337. 
Cerea  flexibilitas,  71,  73. 
Cerebellar  arteries,  409. 
Cerebral  abscess,  437,  438. 
Cerebral  apoplexy,  385,  410,  412, 

448. 
Cerebral    arteriosclerosis,   xiv,    8, 
89,  194,  293,  298,  367,  368, 
405-412,  457,  625,  628,  629. 
Cerebral  compression,  413,  414. 
Cerebral  concussion,  304,  413,  414, 

628. 
Cerebral  embolism,  408,  412,  626, 

632. 
Cerebral   hemorrhage,    391,    408, 

410,  629. 
Cerebral    infarction,     400,     408, 

410. 
Cerebral  softening,  391,  408,  629. 
Cerebral  syphilis,  8,  89,  90,  194, 
364-369,  391,  393,  454,  625, 
630. 
diagnosis,  367-369. 
early  involvement,  364,  365. 
endarteritic  type,  367,  457,  630, 

631. 
gummatous  type,  367,  457,  630, 

631. 
meningitic  type,  365-367,  630. 
prognosis,  369. 
symptoms,  364-367. 
treatment,  368-369. 
Cerebral  thrombosis,  408. 
Cerebral  tumor,  see  Braiin  tumor. 
Cerebropathia   psychica   toxcemica, 
634. 


652 


INDEX  OF  SUBJECTS 


Cerebro-spinal  fluid,  89,  178,  211, 
364,  365,  367,  368,  390,  391, 
396,  401,  438,  449,  468. 

Certificate  of  insanity,  102. 

Chancre,  365,  396,  401. 

Changeable  mood,  62,  371. 

Character  anomalies,  98,  100,  139, 
207,  215,  220,  262,  316,  318, 
357,  371,  630. 

Charas,  355. 

Charitable  organizations,  v,  191, 
192,  215,  217. 

Cheating,  269,  317. 

Chemical  tests,  89,  449. 

Child-bearing  age,  203,  204. 

Childbirth,  10,  119,  256. 

Childhood,  events  of,  45,  78,  127, 
128,  131,  138. 

Chloral,  105,  106,  214,  348,  404, 
626,  633. 

Chloralose,  106. 

Choked  disc,  449,  631. 

Cholera,  427. 

Chorea,  acute,  626,  632. 

Chorea,  Huntington's,  see  Hunt- 
ington's chorea. 

Choreiform  movements,  81,  382, 
411. 

Christian  Science,  114. 

Chromatolysis,  334,  393,  448. 

Chronic  alcoholism,  see  Alcohol- 
ism, chronic. 

Chronic  mania,  290,  291. 

Chronological  age,  95. 

Circle  of  Willis,  405,  406,  407. 

Circular  psychoses,  282,  283,  284, 
287,  288,  289,  626,  635. 

Circulatory  disorders,  64,  234,  256, 
271,  278,  294,  360,  423.  See 
also  Pulse. 

Classification,  193,  194,  260,  625- 
640. 
sociological,  191 

Claustrophobia,  323. 

Clavus  hystericus,  233. 


Clinical  summary,  86. 

Chnics,  out-patient,  119,  147,  153, 

155. 
Clitoris,  122,  123. 
Clouding    of     consciousness,    see 

Consciousness,  clouding  of. 
Clumsiness,  335. 
Coca,  355,  356. 
Cocaine,   8,   112,   194,   357,   626, 

633. 
Cocaine  delirium,  35,  363. 
Cocainism,  30,  119,  363. 
Coensesthesia,  73,  74. 
Cold  baths,  421. 
Cold  douche,  104. 
Collapse,  214,  333,  361,  362,  427, 

433,  442. 
Collapse  delirium,  634. 
Collateral  heredity,  2. 
Colloidal  gold  test,  Lange's,  89, 

368,  391,  452,  455-458. 
Colony,  78,  204.        ; 
Coma,  40,  332,  414,  415,  416,  421, 

426,  438. 
Comatose  drunkenness,  332,  334. 
Combined  sclerosis,  382,  394. 
Commitment,  xiv,  11,  80,  82,  83, 

101-103,  117,  159,  161,  181, 

264,  266,  322,  350,  448,  639, 

640. 
Common  reactions,  548,  551,  552, 

553. 
Common-sense  thinking,  137-139. 
Competence,  legal,  181,  182,  183. 
Complacency,  270. 
Complement,  460,  462. 

absorption  or  fixation  of,  461. 
Complete  dissociation,  552. 
Completion   test,    Trabue's,    621, 

623. 
Complexes,  sexual,  121,  135,  302. 
Complexes,  subconscious,  91,  99, 

120,  140,  145,  301,  548,  638. 
Compression,  cerebral,  413,  414. 
Compunction,  270,  317. 


INDEX  OF  SUBJECTS 


653 


Conceit,  218,  262,  263. 
Concussion,    cerebral,    304,    413, 

414,  628. 
Condensation  in  dreams,  135. 
Conduct,  xiv,  61, 78, 82,  92,  97,  139, 

220,  237,  258,  301,  374,  389. 
Confabulations,  see  Fabrications. 
Confidence,  .113,  140. 
Conflict,   intrapsychic,    131,   259, 

314,  315,  638. 
Confused  mania,  267,  275,  276. 
Confusion,  19,  29,  42,  65,  231,  236, 

243,  251,  292,  295,  345,  373, 

386,  387,  409,  411,  415,  417, 

419,  421,  422-428,  430,  438, 
441,  628,  629,  630,  631,  632, 
633,  634,  637,  639. 

Congenital  syphilis,  78. 

Conjugal  general  paralysis,  399. 

Conscientious  objectors,  218. 

Conscious  motives,  310. 

Consciousness,  20,  28,  33,  40-42, 
46,  47,  49,  51,  52,  65,  67,  68, 
70,  74,  81,  127,  129,  140,  142, 
214,  237,  251,  253,  298,  300, 
301,  310,  319,  320,  336,  342, 
348,  366,  373,  414,  415,  638. 

Consciousness,  clouding  of,  26,  27, 
41,  48,  208,  272,  275,  333,  419, 

420,  422,  429,  430. 
Consciousness,  field  of,  40,  43,  48, 

50,  52,  65,  120. 
Consciousness,   loss   of,   81,   386, 

409,  417. 
Conservation,  amnesia  of,  43,  44, 

445. 
Constipation,  64,   234,   279,  294, 

298,  318,  338,  385,  423,  432. 
Constitutional  disorders,    11,    15, 

16,  100,  193,  260,  316,  327, 

397,  639. 
Constitutional     inferiority,     159, 

260,  627,  638,  639,  640. 
Constitutional  make-up,  see  Make- 
up, psychic,  also  Personality. 


Constitutional  psychopathic 
states,  xiii,  6,  11,  62,  65,  71, 
172,  191,  192,  193,  215-228, 
300,  316,  357.  *See  also  Con- 
stitutional inferiority. 

Consultations,  expert,  91,  93. 

Contemplation,  142. 

Content  of  dreams,  latent,  128, 
129,  133,  137. 

Content  of  dreams,  manifest,  128, 
129,  135,  136,  137. 

Content  of  psychoses,  80,  120. 

Content,  total  mental,  120. 

Continuous  baths,  104,  105,  299. 

Contractures,  233,  300,  303,  309, 
312,  381,  403,  410. 

Contrary  reactions,  73. 

Contributing  causes,  see  Causes, 
contributing. 

Convalescence,  22,  25,  30,  55,  154, 
281,  294,  298,  345,  348,  414, 
416,  426,  428,  634. 

Conventionalities,  regard  for,  332, 
359,  374,  389. 

Convergent  heredity,  327. 

Conversion,  121,  302,  638. 

Convulsions,  77,  79,  81,  206,  213, 
233,  300,  313,  366,  367,  382, 

386,  403,  404,  412,  430. 
Convulsive  drunkenness,  333. 
Cooperation,  76,  81,  82,  97,  631. 
Coordination,  muscular,  7,  81. 
Coprolalia,  321. 
Corruption,  203. 

Cortical  or  short  arterioles,  405, 

407,  408. 
Course  of  psychoses,  80,  86,  253, 

255,  276,  280,  282,  348,  349, 

387,  389,  411,  426,  432,  448, 
630,  636. 

Courts  of  law,  v,  150,  181,  182, 

192,  215. 
Cowardice,  220. 
Cramps,  abdominal,  361. 
Cranial  capacity,  261. 


654 


INDEX  OF  SUBJECTS 


Cranial  malformations,  80,  197. 
Cranial  nerves,  364,  366,  630. 
Credulity,  263. 
Cretinism,  431-,  433,  435. 
Crime,  26,  177,  185,  189,  190,  203, 

208. 
Criminality,  2,  71,  78,  79, 148,  191, 

197,  202,  215,  216,  219,  221, 

303,  317,  332,  357,  383,  387, 

639. 
Criminal  responsibility,  xiv,  181, 

183-185. 
Crises,  organic,  378. 
Critique,  141. 

Critique,  suspension  of,  128,  142. 
Cruelty,  220. 
Crural  monoplegia,  409. 
Culpability,  ideas  of,  see  Ideas  of 

culpability. 
Cup  feeding,  110,  241. 
Curiosity,  357. 
Curves  of  distribution,  normal,  93, 

100. 
Custody,  xiv,  78,  117,  170,    173, 

203,  204. 
Cutaneous  reflexes,  337,  344,  382. 
Cyanosis,  65, 80, 234, 278, 295, 423. 
Cynicism,  269,  270. 

Dangerous  tendencies,  26,  102, 
117,  236,  261,  295. 

Dark  field  illumination,  401. 

Day  dreaming,  128,  138. 

Deaf -mutism,  306,  309. 

Deafness,  30,  300,  309,  364,  366, 
382,  383,  409,  418. 

Death,  214,  252,  276,  293,  294, 
298,  329,  333,  345,  346,  348, 
353,  354,  369,  376,  385,  387, 
388,  390,  403,  409,  412,  414, 
421,  426,  427,  433,  436,  442, 
447,  448,  449,  635. 

Death  of  relatives,  11,  294. 

Death  of  relatives,  dreams  of,  130, 
131. 


Debauchery,  203. 

Decency,  violations  of,  223,  383, 
387,  389. 

Deception,  220,  310,  316. 

Decline  of  mental  disorders,  164. 

Defective  delinquents,  169,  170, 
203. 

Deformities,  cranial,  80,  197. 

Degeneration,  anatomical  stig- 
mata of,  197. 

Deglutition,  disorders  of,  376, 403. 

Dejection,  81.  See  also  Depres- 
sion. 

Delayed  talking,  77,  79,  197. 

Delayed  walking,  77,  79,  197. 

Delinquents,  defective,  169,  170, 
203. 

Delinquents,  juvenile,  186. 

Delire  chronique  a  evolution  sys- 
tematique,  248-251,  266,  350. 

Delire  du  toucher,  323. 

Delirium,  42,  333,  339,  366,  409, 

420,  435,  626,  633,  634,  638. 
Delirium,  cocaine,  35,  363. 
Delirium,  collapse,  634. 
Delirium,  epileptic,  26,  29,  42,  43, 

74,  207-211,  280. 
Delirium,  exhaustion,  10,  626,  634, 

635. 
Delirium,  febrile,  10,  33,  103,  413, 

419-421,  634. 
Delirium,  hallucinatory,  29,  342, 

421,  425. 

Delirium,  infectious,  21,  211,  413, 

419-421,  634,  635. 
Delirium,  initial,  421,  634. 
Delirium,  mystic,  68,  429. 
Delirium,  occupation,  211,  343. 
Delu-ium,  senile,  447,  625,  629. 
Delirium,  toxic,  33,  68,  419,  429. 
Delirium,  transitory,  211. 
Delirium,  traumatic,  9,  194,  414- 

416,  625,  628. 
Delirium  tremens,  7,  26,  35,  40, 

194,  211,  251,  252,  286,  337, 


INDEX  OF  SUBJECTS 


655 


342-348,  413,  430,  447,  626, 
632. 

complications,  345. 

diagnosis,  345. 

pathogenesis,  346. 

pathological  anatomy,  346. 

physical  symptoms,  344. 

prevention  of,  348. 

prodromata,  342,  348. 

prognosis,  344,  345. 

psychic,  symptoms,  342-344. 

treatment,  347-348. 
Delirium,  ursemic,  429,  430. 
Delusional  depression,   277,   279, 

280. 
Delusional  drunkenness,  333,  334. 
Delusional  interpretations,  see  In- 
terpretations,   delusional  or- 
false. 
Delusional  mania,  267,  271-275. 
Delusional  melancholia,  295,  296. 
Delusional    states,    alcoholic,    see 

Alcoholic  delusional  states. 
Delusions,  xiii,  xiv,  28,  41,  54,  55, 
63,  66,  67,  75,  82,  83,  85,  86, 
108,  109,  110,  115,  200,  208, 
210,  236,  237,  245,  248,  250, 
251,  254,  262,  263,  264,  265, 
266,  272,  279,  280,  288,  295, 
296,  297,  298,  333,  338,  345, 
350,  351,  363,  379,  380,  389, 
390,  420,  425,  429,  443,  444, 
447,  629,  635,  637.  See  also 
Ideas. 

absurd,  59,  255,  279,  379,  425, 
446,  447,  637. 

contradictory,  379. 

incoherent,  25,  55,  243,  247,  255, 
275,  380,  387. 

mechanisms  of,  66,  127. 

mobile,  271,  379. 

multiple,  55,  379. 

polymorphous,  244. 

systematized,   26,    55,    69,    60, 
243,  244,  246,  247,  249,  250, 


254,  279,  349,  350,  379,  380, 
430. 
Dementia,  xiii,  22,  24,  31,  35,  44, 
55,  59,  61,  62,  64,  96,  102,  105, 
225,  231,  232,  244,  245,  246, 
249,  250,  252,  254,  298,  361, 
366,  380,  403,  410,  412,  432, 
437,  444,  447.  See  also  Men- 
tal deterioration. 
Dementia,  alcoholic,  see  Alcoholic 

dementia. 
Dementia,  arteriosclerotic,  88.  See 
also  Cerebral  arteriosclerosis. 
Dementia,    epileptic,     200,     206, 

637. 
Dementia  paralytica,   see  General 

paralysis. 
Dementia  prsecox,  6,  9,  12,  14,  16, 
29,  44,  51,  52,  60,  62,  102, 
109,  192,  193,  227,  229-261, 
279,  285,  286,  290,  319,  327, 
338,  350,  377,  390,  425,  627, 
6628,  32,  633,  635,  636,  639, 
640. 

catatonic  form,  236-243. 

common  symptoms,  230-234. 

delusional  forms,  243-251. 

diagnosis,  251,  252. 

etiology,  255. 

hebephrenic  form,  229,  627,  636. 

paranoid  form,  627,  636.  See 
also  delusional  forms  and 
Paranoid  dementia. 

pathological  anatomy,  260,  261. 

prognosis,  252. 

psychoses  allied  to,  100,  260, 
636. 

simple  form,  234,  235,  627,  637. 

somatic  disorders,  233. 

theories  of,  256-260. 

treatment,  261. 
Dementia,   senile,   see  Senile  de- 
mentia. 
Dementia,  traumatic,  9,  194,  418, 
628. 


656 


INDEX  OF  SUBJECTS 


Demorphinization,  361,  362,  363. 

Dependency,  148,  191,  197,  200, 
201,  203,  215. 

Deportation  of  defective  immi- 
grants, 180. 

Depression,  xiv,  19,  28,  61,  63-69, 
74,  82,  99,  108,  200,  201,  236, 
237,  240,  243,  244,  245,  247, 
252,  267,  269,  276,  277,  278, 
280,  281,  282,  286,  287,  288, 
289,  290,  291,  294,  297,  319, 
324,  349,  367,  387,  389,  408, 
429,  441,  445,  447,  625,  628, 
629,  630,  631,  634,  635,  636, 
638,   639.     See  also  Psychic 
pain  and  Sadness, 
active,  63,  65,  68,  292. 
delusional,  277,  279,  280. 
passive,  63,  68,  278. 
recurrent,  283. 
simple,  277,  279,  280. 
stuporous,  74,  277,  280. 

Dermatograpiiia,  234. 

Desertion,  11. 

Despair,  63,  66,  285,  295,  372. 

Deterioration,  mental,  see  Mental 
deterioration. 

Determiners,  germ-plasmic,  2,  3. 

Determinism,  psychic,  120. 

Development,  arrests  of,  see  Ar- 
rests of  development. 

Development,  mental,  78,  90. 

Development,  normal  course  of, 
474,  475. 

Development,  sexual,  122-124. 

Developmental  units,  95. 

Diabetes,  91. 

Diagnosis,  28,  45,  76,  86,  88,  89, 
91,  98, 102,  150,  151,  152,  173, 
174,  180,  201,  202,  210,  251, 
252,  265,  266,  285,  301,  345, 
350,  354,  360,  367,  390,  411, 
427,  430,  437,  438,  448,  630, 
631,  640. 

Diagnosis,  differential,  303,  309, 


310,  312,  313,  338,  350,  368. 

391,  411,  419,  438,  448   449, 

629. 
Diaphoretics,  430. 
Diarrhoea,  68,  361,  385,  441,  442, 

638. 
Diet,  213,  281,  311,  348,  354,  362, 

428,  446. 
Differential  psychology,  100. 
Digestive  disorders,  64,  234,  279, 

292,  294,  298,  338,  345,  423, 

432. 
Digitalein,  348. 
Digitalis,  362. 
Digit-span  test,  621,  622. 
Diplopia,  372. 
Dipsomania,  77,  321,  632. 
Direct  heredity,  2. 
Directed  thinking,  137-139. 
DisabUity,  300,  374. 
Disaggregation,   psychic,   51,   58, 

75,  245,  250,  361. 
Disappointment  in  love,  11. 
Discharge  of  patients,  77, 117-119, 

173. 
Discipline,  204,  220,  306. 
Disconnectedness,  51,  82,  332,  414, 

420. 
Discouragement,     63,     70,     219, 

277,  285,  297,  319,  371,  372. 
Disgust  for  existence,  108. 
Disgust  for  food,  109. 
Disheveled  appearance,  81. 
Dishonesty,  126,  269,  316. 
Disorientation,  40,  65,   251,  275, 

286,  352,  353,  354,  408,  414, 

415,  424,  426,  429,  447,  628, 

632. 
allopsychic,  41,  252,  320. 
autopsychic,  74. 
of  person,  74. 
of  place,  208,  415,  444. 
of  time,  46,  208,  415,  444. 
Displacement  of  affect,  129,  135, 

136. 


INDEX  OF  SUBJECTS 


657 


Disregard  for  others,  125. 
Dissatisfaction,  328. 
Dissimilar  heredity,  2,  327. 
Dissimulation,  86. 
Dissipated  persons,  397. 
Dissociation,  complete,  552. 
Dissociation,  partial,  552. 
Distractibihty,    48,    82,    92,    268, 

274,  332. 
Distribution,  normal  curves  of,  93, 

100. 
Distrustfulness,  349. 
Disturbed  patients,  105.    See  also 

Excitement. 
Diversion,  therapeutic,  261. 
Dizziness,  364,  365,  408,  417,  452, 

629,  630,  631,  638. 
Dolichocephaly,  197. 
Domestic  troubles,    10,    79,    148, 

340. 
Dominant  condition,  3,  5,  328. 
Dormitories,  104,  105. 
Dotards,  xiv,  445. 
Doubling  of  personality,  301. 
Doubt,  278,  319,  321,  324,  638. 
Doubtful  reactions,  548,  551,  552, 

553. 
Doubting  mania,  322,  323. 
Douche,  cold,  104. 
Dramatization     in     dreams,     see 

Moulding  for  presentability. 
Dream  delirium,  55,  420. 
Dream  stimuli,  127,  128. 
Dream  thinking,  135-139. 
Dreams,   27,    127-137,    138,   141, 

209,  344,  350,  415. 
affect  in,  130,  137. 
biological  purpose  of,  129. 
condensation  in,  135. 
displacement  in,  136. 
distortion  in,  128,  136. 
egotistic  nature  of,  136. 
exhibitionism  in,  131. 
forgetting  of,  128,  209. 
in  chronic  alcoholism,  337. 


Dreams,   interpretation   of,    127- 
137,  142-145. 
latent  content  of,  128,  129,  133, 

137. 
manifest  content  of,   128,  129, 

135,  136,  137. 
material  of,  127,  128,  129. 
mechanisms  of,  127,  135. 
occupation,  337,  415. 
of     death     of     relatives,     130, 

131. 
of  falling,  130,  131. 
of  nakedness,  130,  131. 
peculiarities  of,  127,  128. 
sexual  material  of,  130,  133. 
substitution  in,  137. 
symbolism   in,    131,    133,    134, 

135,  144. 
theory  of,  128. 
typical,  130. 
Dress,  60,  237,  268,  272. 
Dropsy,  80. 
Drowsiness,  408. 

Drug  addictions,  2,  8,  77, 148,  165, 
166,  167,  170,  172,  174,  178, 
191,  194,  215,  216,  331,  347, 
355-383,  627,  640. 
Drunkards,  203. 

Drunkenness,    7,    177,     331-334, 
346. 
comatose,  332,  334. 
common,  332. 
convulsive,  333. 
delusional,  333,  334. 
maniacal,  333,  334. 
pathological,  194,  331-334,  626, 

632. 
treatment,  334. 
"Dry  retching,"  338. 
Ductless  glands,  626,  634,  635. 
Duplex  inheritance,  4. 
Duplicity,  205. 

Dura  mater,  lesions  of,  330,  392. 
Duration  of  psychoses,  33,  80,  103, 
210,  276,  280,  294,  299,  345, 


658 


INDEX  OF  SUBJECTS 


348,  350,  354,  363,  387,  390, 

414,  426,  448. 
Dynamometer  test,  81. 
Dysarthria,  410. 
Dyspepsia,  294,  345. 
Dysphagia,  409,  441. 
Dyspnoea,  430. 

Ears,  abnormalities  of,  30,  91. 

Eccentricities,  78,  79,  296,  303. 

Echolalia,  71,  239,  471. 

Echo  of  thought,  245,  250. 

Echopraxia,  71,  239. 

Eclampsia,  78. 

Ecstasy,  25,  68,  210,  258,  637. 

Education,  1,  16,  24,  83,  90,  139, 
150,  155,  171,  179,  184,  197, 
202,  212,  220,  228,  318. 

Educational  psychology,  99. 

Educational  therapeutics,  99. 

Efficiency,  intellectual,  174. 

Egotistic  nature  of  dreams,  136. 

Elation,  see  Euphoria. 

Emaciation,  241,  298,  324,  361, 
441,  442. 

Embarrassment,  130,  482. 

Embezzlers,  357. 

Embolism,  cerebral,  408,  412,  626, 
632. 

Emissions,  seminal,  319. 

Emotional  control,  202,  629. 

Emotional  disorders,  302,  304. 

Emotional  instability,  216,  219, 
285,  310,  408. 

Emotions,  see  Affectivity. 

Employment,  10,  173,  202,  204. 

Encephalitis,  chronic  diffuse  in- 
terstitial, 409. 

Endarteritis,  365,  367,  399,  407, 
411. 

End-pleasure,  sexual,  122. 

Endurance,  lack  of,  318. 

Energy,  317. 

Enterprise,  317. 

Enuresis,  nocturnal,  122. 


Environmental  factors,  11,  76,  80, 
124,  151,  153,  162,  179,  184, 
201,  356,  400. 
Environment,  rural,  14,  401. 
Environment,  urban,  14,  17,  401. 
Ependymal  granulations,  392,  394. 
Epidemics  of  suicide,  108. 
Epilepsy,  xiv,  2,  6,  9,  11,  12,  42, 
68,  71,  77,  122,  159,  172,  173, 
174,  191,  192,  193,  196,  200, 
203,  205-214,  215,  216,  221, 
225,  227,  260,  289,  303,  313, 
316,  327,  333,  386,  390,  417, 
627,  632,  637,  640.  | 

Jacksonian,  345,  386,  417,  438. 
masked,  210. 
paroxysmal  mental  disorders  in, 

205-211. 
permanent  mental  disorders  in, 

205,  206. 
prevention  of,  212. 
senile,  447.  -i 

traumatic  9,  194,  417,  418,  628. 
treatment  of,  212-214. 
Epileptic  absence,  42,  207. 
Epileptic  aura,  81,  206. 
Epileptic  automatism,  207,  637. 
Epileptic  delirium,  26,  29,  42,  43, 
74,  207-211,  280. 
diagnosis,  210,  211. 
duration,  210. 
symptoms,  208-210. 
treatment,  214. 
Epileptic  dementia,  200,  206,  637 
Epileptic  furor,  68,  208. 
Epileptic  mania,  211. 
Epileptic  personality,  205. 
Epileptic  stupor,  207,  210. 
Epileptic  vertigo,  206. 
Epileptiform    seizures,    in    acute 
alcoholism,  333. 
in  brain  tumor,  438. 
in  cerebral  arteriosclerosis,  408, 

410. 
in  cerebral  syphilis,  367. 


INDEX  OF  SUBJECTS 


659 


Epileptiform  seizures,  in  delirium 

tremens,  345. 
in  dementia  prsecox,  233,  256. 
in  drug  addictions,  361,  363. 
in  general  paralysis,  372,  375, 

379,  382,  386,  390. 
in  malingering,  309. 
in  senile  dementia,  447. 
Erogenous  zones,  121,  122. 
Eroticism,  202,  223,  243,  268,  269, 

447. 
Errors,  motivated,  127. 
Errors,  orthographic,  376. 
Eruptions,  80,  384,  399. 
Eruptive  fevers,  427. 
Erj^hrophobia,  323. 
Escape  of  thought,  37. 
Essential  causes,  see  Causes,  essen- 
tial. 
Etat  crible,  410. 
Ether,  214,  334,  348. 
Ethical  motives,  141. 
Etiology,  1,  77,  80,  118,  193,  195, 

212,  255,  284,  301,  303,  304, 

306,  339,  356,  357,  395-401, 

413,  427,  434,  439,  443,  640. 

See  also  Causes. 
Eugenics,  155,  164,  171,  180,  212. 
Euphoria,  61,  68-70,  210,  219,  243, 

267,  268,  271,  275,  282,  293, 

331,  332,  353,  358,  371,  387, 

389,  445,  447,  448. 
active,  68. 
calm,  68. 
Exacerbation,  103,  280. 
Examination    for    aphasia,    470- 

473. 
Examination,  mental,  59,  81-86, 

202. 
Examination,  methods  of,  76,  80- 

87. 
Examination,    physical,    80,    140, 

202. 
Excitement,  xiv,  41,  68,  69,  70, 

82,  99, 101,  102, 104,  214,  240, 


242,  243,  244,  247,  251,  253, 
261,  267,  269,  270,  271,  275, 
276,  280,  281,  282,  286,  287, 
288,  289,  290,  291,  331,  332, 
333,  342,  343,  350,  361,  367, 
373,  375,  380,  387,  389,  402, 
411,  420,  421,  425,  426,  632, 
634,  636,  637,  639. 
catatonic,    211,    236-243,    254, 

290,  637. 
in  general  paralysis,  373,  375, 

380,  387,  389,  402. 
in  mental  deficiency,  200-201. 
treatment  of,  103-107. 

Exciting  causes,  118,  399. 

Exercise,  428. 

Exhaustion  deUritun,  10,  626,  634, 
635. 

Exhaustion  psychoses,  194,  391, 
422^28,  634. 

Exhibitionism,  131,  224,  225,  383. 
in  childhood,  131. 
in  dreams,  131. 

Exophthalmic  goiter,  431,  435- 
436. 

Expansiveness,  68,  429. 

Experimental  pharmaco-psychol- 
ogy,  99. 

Experimental  psychopathology, 
99. 

Expert  witnesses,  183. 

Expression,  facial,  67,  69,  207,  222, 
268,  295,  361,  426,  431.  See 
also  Physiognomy. 

Extramural  psychiatry,  190-192. 

Exuberant  temperament,  285. 

Eye  color,  heredity  of,  3,  259. 

Eyes,  abnormalities  of,  91. 

Fabrications,  221,  352,  354,  414, 

415,  416,  629,  632. 
Facetiousness,  631,  633. 
Facial  expression,  see  Expression, 

facial. 
Facial  paralysis,  344, 366, 381, 409. 


660 


INDEX  OF  SUBJECTS 


Fainting  spells,  77,  79,  206,  233, 
303,  318,  408,  441,  629. 

Faith,  in  psychotherapy,  113,  114. 

Falling,  dreams  of,  130,  131. 

False  ideas,  54. 

False  interpretations,  see  Interpre- 
tations, delusional  or  false. 

Family  history,  see  History,  fam- 

iiy. 

Family  suicide,  108,  296,  322. 

Fanaticism,  205. 

Fatigability,  252,  292,  373,  408, 
416,  628,  629,  638. 

Fatigue,  50,  70,  332,  380,  371,  638. 

Faultfinding,  257,  258. 

Fear,  28,  108,  109,  130,  131,  133, 
258,  279,  280,  319,  324,  325, 
326,  447,  479,  632,  637,  638. 

Febrile  delirium,  see  Delirium, 
febrile. 

Feeble-mindedness,  2,  24,  26,  98, 
148,  169,  170,  173,  185,  187, 
188,  189,  190,  191,  195-204, 
206,  212,  215,  216,  220,  221, 
265,  303,  310,  551,  639.  See 
also  Arrests  of  development 
and  Mental  deficiency. 

Feeding,  cup,  110,  241. 
forced,  110,  299,  428. 
rectal,  214. 
spoon,  110. 
tube,  110-112,  241,  298. 

Female  sex,  see  Sex. 

Fetichism,  224,  225. 

Fever,  344,  421,  423,  438,  442. 

Fibrosis,  arterio-capillary,  408. 

Field  investigation,  77,  154. 

Filial  paranoiacs,  265. 

Filthy  tendencies,  239,  241,  276, 
280,  402,  446. 

Financial  difficulties,  10,  294,  340, 
444. 

Financing  of  institutions,  171,  187. 

Fixation,  amnesia  of,  see  Amnesia 
of  fixation. 


Fixed  ideas,  see  Ideas,  fixed, 

Flexibilitas  cerea,  71,  73. 

Flexibility,  waxy,  71,  73. 

Fhght  of  ideas,  50,  51,  52,  69,  82, 
85,  211,  231,  267,  268,  275, 
281,  282,  286,  287,  288,  290, 
291,  293,  332,  373,  425,  447, 
635. 

Floating  kidney,  318. 

Flow  of  thought,  82,  91,  98.  See 
also  Disconnectedness,  Flight 
of  ideas  and  Incoherence. 

Focal  symptoms,  411,  438,  631. 

Follow-up  work,  153,  155. 

Food,  refusal  of,  see  Refusal  of 
food. 

Forced  feeding,  110,  299,  428. 

Foreign-born  insane,  17,  18. 

Foreign  or  mixed  parentage,  17, 
18. 

Fore-pleasure,  sexual,  122,  124. 

Forgetfulness,  125,  408,  416,  417, 
628,  629,  630; 

Forgetting,  motivated,  124,  125, 
126,  257. 

Forgetting  of  dreams,  128,  209. 

Form  of  psychoses,  120. 

Fracture  of  skull,  79,  413,  628. 

Fractures,  spontaneous,  383. 

Free  association  test  (Kent- 
Rosanoff),  547-620. 

Free  will,  xiv,  183,  184. 

Frequency,  surface  of,  94. 

Frequency     tables,     association, 
554-602. 
appendix  to,  603-620. 

Friendliness,  140. 

Fright,  304,  308. 

Frigidity,  sexual,  124,  223,  224. 

Fuchs-Rosenthal  counting  cham- 
ber, 452,  453,  454. 

Fumbling,  257. 

Furor,  epileptic,  68,  208. 

Furunculosis,  331. 

Futility,  319. 


INDEX  OF  SUBJECTS 


661 


Gaiety,  298. 

Gait,  81,309,332,438,441. 

Gamblers,  357. 

Ganglionic    arterioles,    405,    406, 

410. 
Gangsters,  357. 
Gonja,  355. 

Gastric  lavage,  112,  428. 
Gastritis,  339. 
Gastro-intestinal    disorders,    281, 

338,  347,  361,  362,  385,  417, 

446,  448.  See  also  Anore.xia, 
Appetite,  Constipation,  Diar- 
rhoea, "Dry  retching,"  Dys- 
pepsia, Indigestion,  Nausea, 
Vomiting,  etc. 

General  hospitals,  psychopathic 
wards  in,  181. 

General  nutrition,  see  Nutrition, 
general. 

General  paralysis,  8,  10,  12,  13,  14, 
15,  16,  25,  28,  29,  38,  44,  45, 
59,  61,  68,  69,  75,  86,  88,  89, 
90,  109,  118,  192,  194,  211, 
232,  251,  269,  286,  335,  338, 
345,  346,  365,  366,  367,  368 
370-404,  411,  413,  425,  438, 

447,  448,  454,  457,  625,  628, 
630,  631,  632. 

conjugal,  399. 

course,  389. 

diagnosis,  390. 

duration,  390. 

essential  symptoms,  372-378. 

etiology,  395-401. 

forms,  386-389. 

galloping,  387,  390. 

inconstant  symptoms,  378-386. 

infantile,  400. 

juvenile,  78,  400. 

pathological  anatomy,  392-394. 

prevention,  401. 

prodromata,  371-372. 

prognosis,  389-390. 

remissions  in,  118. 


General  paralysis,  treatment,  402- 
404. 
trepojiema  pallidum  in,  396-399. 

General  paresis.  See  General 
paralysis. 

General  sensibility,  hallucinations 
of,  see  Hallucinations  of  gen- 
eral sensibility. 

Generative  function,  disorders  of, 
383. 

Genes,  2. 

Genital  zones,  122. 

Genius,  198. 

German  race,  12. 

Germinal  factors,  2. 

Germ-plasmic  determiners,  2,  3. 

Gestures,  69,  237,  240,  243,  268, 
271,  470. 

Giddiness,  318.  (See  a?so  Dizziness. 

Girdle  sensation,  388. 

Gliosis,  perivascular,  407. 

Globulin,  364,  450. 

Globus  hystericus,  233,  338. 

Gloomy  mood,  277,  282,  371,  372. 

Goiter,  exophthalmic,  431,  435- 
436. 

Gothenburg  system,  175,  176. 

Grandeur,  ideas  of,  see  Ideas  of 
grandeur. 

Graphorrhoea,  271. 

Grief,  256,  292,  340,  341. 

Grimaces,  232,  238,  240,  270, 
637. 

Group  tests,  psychological,  97, 
621-624. 

Guardianship,  204. 

Guiding  idea,  49. 

Guilt,  184,  185,  187. 

Gummata,  8,  365,  367,  399. 

Gustatory  hallucinations,  see  Hal- 
lucinations, gustatory. 

Gynecological  troubles,  91. 

Habit-forming  drugs,  105,  177, 
355-363. 


662 


INDEX  OF  SUBJECTS 


Habits,  98,  99,  179,  203,  257,  258, 
331. 

Hoeiyiatoma  auris,  383,  384. 

HEemolj^sis,  460. 

Hair,  in  hypothyroidism,  432,  435. 

Hair  despoilers,  225. 

HaUuctnations,  xiii,  19,  21-39,  41, 
53,  55,  58,  63,  82,  83,  102,  109, 
206,  208,  210,  236,  237,  243, 
244,  245,  246,  247,  249,  250, 
251,  253,  254,  255,  258,  263, 
266,  272,  275,  279,  280,  286, 
288,  296,  320,  333,  342,  343, 
344,  349,  350,  351,  353,  363, 

379,  380,  387,  411,  419,  430, 
441,  447,  631,  632,  633,  634, 
635,  637,  639. 

agreeable,  25,  32,  35,  425,  426. 

auditory,  22,  30,  31,  32,  33,  53, 

247,  296,  297,  348,  349,  363, 

380,  425,  447. 
combined,  26,  27,  342,  425. 
conscious,  23,  25,  29. 
content  of,  32. 
definitions  of,  21,  22. 
diagnosis  of,  27. 
etiology  of,  29. 

genital,  35,  245,  2.50. 

gustatory,  34,  35,  250,  296,  349, 
363. 

hypnagogic,  342. 

imperative,  26,  108. 

indifferent,  25. 

induced,  30,  344. 

motor,  35,  36,  37,  58,  75,  245, 
250,  296,  297,  320,  349,  363. 

motor  graphic,  37. 

motor  verbal,  36,  37,  38,  53. 

of  general   sensibility,    35,    58, 
250,  255,  296,  342. 

of  memory,  46,  47,  352,  445. 

olfactory,  34,  35,  38,  250,  296, 
349,  363. 
Hallucinations,     painful     or    un- 
pleasant, 25,  26,  32,  35,  58, 


243,  245,  249,  342,  425,  426, 

429. 
peripheral,  29,  30. 
pleasing,  25,  32,  35,  425,  426. 
properties  of,  22. 
psychic,  53,  54,  75. 
reflex,  29. 
suggested,  30. 
tactile,  35,  363. 
theories  of,  38. 
unilateral,  29. 
verbal    auditory,    31,    53,    58, 

249. 
visual,  23,  30,  33,  34,  53,  240, 
247,  250,  279,  296,  297,  342, 
348,  363,  420,  425,  447. 
Hallucinatory  delirium,  29,   342, 

421,  425. 
Hallucinosis,  acute,  see  Acute  hal- 
lucinosis. 
Hallucinosis,  chronic,  626,  632. 
Handwriting,  81,  85,  271,  278,  375, 

376. 
Hanging,  suicidal,  108,  297. 
Harping,  258. 
Hashish,  355. 
Hatred,  131. 

Headache,  80,  235,  239,  279,  295, 
297,  318,  342,  364,  365,  371, 
408,  416,  417,  422,  433,  438, 
452,  628,  629,  630,  631. 
sick,  78,  303. 
Head  injury,  2,  9,  10,  78,  79,  165, 
178,  179,  399,  413,  414,  628. 
See  also  Traumatism. 
Health  board,  192,  215. 
Hearing,     hallucinations    of,    see 

Hallucinations,  auditory. 
Heart  lesions,  80,  91, 106,  300,  346, 

395,  399,  408. 
Heart  stimulants,  348,  362. 
Hebephrenia,  229,  627,  636. 
Hebetude,  631. 
Hebrew  race,  12. 
Helmet  sensation,  371. 


INDEX  OF  SUBJECTS 


663 


Hemiansesthesia,  crossed,  409. 
Hemianopsia,  81,  367,  409,  438. 
Hemiplegia,   233,   367,   381,  410, 

438,  447. 
Hemoglobin,  80,  378. 
Hemorrhage,    10,   351,   408,   413, 

414,  427,  634. 
Hemorrhagic  pachymeningitis,  in- 
ternal, 330,  392. 
Hemp,  Indian,  355. 
Hereditary  syphilis,  see  Syphilis, 

congenital  or  hereditary. 
Heredity,  2,  9,  11,  18,  154,  165, 
166,  170,   171,  174,   184,  195, 
212,  239,  255,  259,  285,  292, 
296,  303,  327,  339,  397,  434, 
443,  631. 
atavistic,  2,  328. 
collateral,  2. 
convergent,  327. 
direct,  2. 
dissimilar,  2,  327. 
Mendelian  theory  of,  3. 
of  eye  color,  3,  259. 
similar,  2,  78,  285,  327. 
Heroin,  8,  194,  357. 
Herpes,  384. 

History,  clinical,  28,  88,  211,  395, 
640. 
family,  76,  77,  78,  80,  167,  202, 
215,  296,  303,  316,  327,  328, 
356,  357,  397,  443,  631. 
of  psychosis,  80,  118,  202. 
personal,  78,  167,  202,  215,  316, 

356,  357,  368. 
social,  150,  202. 
taking,  76,  140,  151,  155. 
venereal,  76,  79. 
Homicidal  tendency,  26,  295,  321, 

351. 
Hopefulness,  140. 
Hospitals,  see  Institutions. 
Hostility,  132. 

Humility,   ideas  of,  see  Ideas  of 
humiUty. 


Huntington's  chorea,  11,  78,  193, 

327-330,  625,  631. 
Hydrocephalus,  78. 
Hydrotherapy,  103,  104. 
Hygiene,     mental,     see     Mental 

hygiene. 
Hygienic  measures,  118,  212,  213, 

258,  448. 
Hyoscine,  107. 
Hypersesthesia,  309,  338,  344,  353, 

360,  366,  381,  382,  638. 
Hyperthyroidism,  431,  435-436. 
Hypnagogic  hallucinations,  342. 
Hypnal,  106. 

Hypnotics,  105-107,  308,  348. 
Hy-pnotism,  71,  83,  113,  306,  312. 
Hyposesthesia,  300,  338,  382,  446. 
Hypochondriacal  disposition,  78, 

79,  318. 
Hypochondriacal  ideas,  see  Ideas, 

hjrpo  chondriacal . 
Hypochondriacal  paranoiacs,  265. 
Hypochondria  cum  materia,  56. 
Hypodermic  medication,  106,  107, 

214,  360. 
Hypothyroidism,  431-435. 
Hysteria,  xiv,  74,   77,   233,   258, 

300-317,  318,  327,  627,  632, 

638. 
Hysteria,  traumatic,  301,  308. 
Hysterical  personality,  303,  312, 

316,  317. 
Hysteriform    seizures,    233,    235, 

257,  295,  306,  338,  361. 
Hystero-neurasthenia,  318. 

Idea,  guiding,  49. 
Ideas,  association  of,  see  Associa- 
tion of  ideas, 
autocthonous,   23,    50,   52,    .^3, 

58,  75,  245,  250. 
community  of,  99. 
expansive,  244. 
false,  54. 


664 


INDEX  OF  SUBJECTS 


Ideas,  fixed,  50,  52,  108,  218,  262, 
263,  279,  288,  297,  320,  322, 
420. 
h5^ochondriacal,    56,  57,    109, 

245,  249,  258,  272,  277,  279, 
296,  379,  441,  636,  638. 

imaginary,  54. 

imperative,  23,  50,  52,  53,  72, 

226,  279,  288,  297,  319,  320, 

321. 
melancholy,    55-59,    237,    243, 

244,  245,  246,  275,  296,  333, 

379,  388,  425,  429,  447. 
metaphysical,  57. 
mystic,  210,  245,  636. 
of  culpability,  55,  56,  58,  245, 

296,  379. 
of  grandeur,  55,  59,  60,  210,  243, 

246,  247,  250,  262,  271,  272, 
273,  274,  275,  379,  387,  425, 
447,  637. 

of  humHity,  55,56,245,  279,  296. 

of  immensity,  57. 

of  immortality,  57. 

of  jealousy,  326,  349,  351,  363, 

447,  633. 
of  negation,  56,  57,  245,  296, 

321,  379,  447. 
of  persecution,  55,  57,  58,  59, 

102,  108,  115,  201,  243,  246, 

247,  249,  250,  262,  272,  275, 
279,  296,  329,  333,  336,  349, 
361,  379,  380,  425,  429,  441, 
446,  447,  629,  633,  637. 

of  possession,  37,  75,  245,  258. 

of  reference,  258,  636. 

of  ruin,  56,  245,  279,  296,  379, 

447. 
of  self-accusation,  55,  279,  297, 

325,  447. 
stock  of,  235,  335,  432,  445. 
subconscious,  91,  548,  637. 
undesired,  142. 
Idiocy,  68,  74,  195-204,  232,  435, 

639. 


Illegitimacy,  10,  186,  203,  204. 

Illiteracy,  16,  97,  201. 

Ill-natured  disposition,  62,  431. 

Illness  of  relatives,  11. 

Illuminating  gas  poisoning,  633. 

Illusions,  19,  20,  21,  27,  36,  41, 
206,  245,  249,  250,  272,  273, 
275,  277,  279,  287,  296,  333, 
342,  349,  353,  363,  380,  415, 
419,  420,  425,  444,  635. 
of  memory,  46,  47,  352,  445. 

Imaginary  ideas,  54. 

Imaginary  perceptions,  see  Hallu- 
nations. 

Imbecility,  xiv,  74,  85,  159,  195- 
204,  331,  435,  639. 

Immensity,  ideas  of,  57. 

Immigrants,  deportation  of,  180. 

Immigration,  1,  17,  163,  180. 

Immorality,  2,  148,  168,  170,  397. 

Immortality,  ideas  of,  57. 

Immune  serum,  460. 
inactivation  of,  460. 
reactivation  of,  460. 

Imperative  hallucinations,  26,  108. 

Imperative  ideas,  see  Ideas,   im- 
perative. 

Imposed  morality,  316,  317. 

Impotence,  319,  383. 

Improvidence,  216. 

Impulses,  conscious,  72. 
homicidal,  321. 
morbid,  xiii. 
of  passion,  71,  72,  219. 
simple,  71,  72. 
suicidal,  321,  322. 

Impulsiveness,  68,  71,  219,  221, 
232,  295,  336,  389,  435,  636. 

Impulsive   obsessions,    225,    320, 
321. 

Impulsive  reactions,  see  Reactions, 
impulsive. 

Inaccessibility,  411,  640. 

Inaccurate  perceptions,   see  Illu- 
sions. 


INDEX  OF  SUBJECTS 


665 


Inactivation  of  immune  scrum, 
460. 

Inadequate  personality,  216,  258. 

Inanition,  119,  427. 

Incendiarism,  188,  189,  200. 

Incest,  123. 

Incidence  of  mental  disorders,  163, 
166. 

Incidental  causes,  see  Causes,  con- 
tributing or  incidental. 

Incoherence,  50,  51,  52,  82,  85, 
92,  231,  236,  240,  254,  425, 
633. 

Incoherent  delusions,  see  Delu- 
sions, incoherent. 

Incompetence,  legal,  xiv,  182. 

Inconsistency,  205,  374. 

Incoordination,  muscular,  see  Mus- 
cular incoordination. 

Increase  of  mental  disorders  (?), 
160. 

Indecision,  278,  422,  424. 

Indian  hemp,  355. 

Indifference,  41,  61,  220,  224,  231, 
235,  236,  243,  246,  248,  2.52, 
253,  255,  258,  277,  278,  280, 
286,  287,  335,  336,  353,  359, 
373,  386,  425,  431,  445,  473, 
636.  See  also  Apathy, 
conscious,  62. 
unconscious,  62. 

Indigestion,  234. 

Individual  differences,  100. 

Individual  reactions,  see  Reac- 
tions, individual. 

Indolence,  200,  317. 

Induced  hallucinations,  30,  344. 

Industrial  organizations,  97,  150, 
192. 

Inebriety,  148,  173,  191,  212,  341, 
357. 

Inefficiency,  319. 

Inertia,  64,  70,  280,  332,  431,  432, 
631. 

Infancy,  78,  79, 121,  195,  431,  474. 


Infantile  cerebral  paralysis,  200. 
Infantile  fixation  of  libido,  124. 
Infantile  general  paralyses,  400. 
Infantile  onanism,  122. 
Infantile  psychology,  131,  132. 
Infantile  sexuaUty,  121,  122,  124, 

314. 
Infarction,     cerebral,    400,     408, 

410. 
Infectious  delirium,  see  Delirium, 

infectious. 
Infectious     psychoses,    55,     194; 

634. 
Infections,  10,  78,  256,  257,   341, 

347,  351,  388,  394,  413,  419, 

427,  626. 
Infelicity,  domestic,  10,  11,  79. 
Infidelity,  marital,  11. 
Infiltration,  perivascular,  367,  393. 
Infiltration,  pial,  367,  393. 
Infirmity,  psychic,  xiii,  xiv,  11. 
Influenza,  299,  346,  347,  351,  354, 

427,  441,  634. 
Inherited    syphihs,    see    Syphilis, 

congenital  or  hereditary. 
Inhibiting  obsessions,  320,  322. 
Inhibition,  psychic,  xiii,  57,  63,  66, 

70,  99,  277,  280,  282,  287,  288, 

293,  294,  295,  296,  298,  332, 

361,  387,  635. 
Initial  delirium,  421,  634. 
Initial  lesion,  365,  396,  401. 
Initiative,  216,  328. 
Injury,  head,  see  Head  injury. 
Inoffensive  insane,  102. 
Insane,  foreign-born,  17,  18. 
in  institutions,    160,    163,    173, 

212. 
native,  17,  18. 
of  foreign  or  mixed  parentage, 

17,  18. 
reasoning,  see  Paranoia. 
Insanity,  xiv,  1,  14,  15,  16,  17,  18, 

26,  83,  148,  159,  177,  188,  190, 

191,  221,  303.       - 


666 


INDEX  OF  SUBJECTS 


Insanity,  moral,  220. 

physicians'  certificate  of,  102. 
plea  of,  185. 
Insight,  54,  84,  269,  374,  408,  411, 

416,  445. 
Insomnia,  235,  236,  243,  271,  277, 

292,  295,  297,  298,  361,  402, 

408,  435,  634,  635. 
Instability,   emotional,   216,   219, 

285,  310,  408. 
Instincts,  26,  97,  258,  259,  636. 
Institutions,  V,  11, 14, 15, 17, 76,77, 

78, 100, 101-103, 108, 117, 118, 

147,  154,  160,  161,  170,  173, 

176,  181,  185,  192,  200,  261, 

328,  340,  361,  379,  384,  402. 
accessibility  of,  15. 
capacity  of,  173. 
financing  of,  171,  187. 
Insufficiency    of    perception,    see 

Perception,  insufficiency  of. 
Intellectual  eflaciency,  174. 
Intellectual  obsessions,  320,  321. 
Intelligence,  degrees  of,  24,   197, 

198,  202,  318. 
Intelligence,  measuring  scales  of, 

90,  95,  96. 
Intelligence   Quotient,   198,    480- 

481. 
Intelligence  tests,  90,  96. 
Intemperance,  7,  9,   10,   11,   114, 

159,  166,  176,  303,  340,  351, 

356. 
Interests,  61,  259,  418,  445,  628, 

636,  637,  639. 
Interference,  psychic,  73. 
Internal  capsule,  410. 
Internal  hemorrhagic  pachymen- 
ingitis, 330,  392. 
Interpretation  of  dreams,  127-137, 

142-145. 
Interpretations,  delusional  or  false, 

54,  56,  58,  245,  249,  262,  263, 

264,  296,  297,  349,  363,  633, 

637. 


Intimacy,  140. 

Intoxications,  28,  79,  443. 

Intracranial  medication,  402. 

Intracranial  pressure,  89,  438,  449, 
631. 

Intrapsychic  conflict,  131,  259, 
314,  315,  638. 

Intraspinal  medication,  365,  401, 
402. 

Intrauterine  life,  78,  195,  196. 

Intravenous  medication,  401. 

Inventors-paranoiacs,  265. 

Inversion,  sexual,  78,  79,  223,  224, 
226. 

"Invisible  ones,"  32. 

Involutional  melancholia,    6,    13, 
55,  62,  68,  108,  193,  245,  278, 
279,  286,  292-299,  327,  387, 
390,  448,  627,  635.     See  also 
Melancholia, 
causes,  292. 
duration,  299. 
prodromata,  292. 
prognosis,  294,  298. 
symptoms,  294-298. 
treatment,  299. 

Iodides,  368. 

lodothyrine,  433. 

Irish  race,  12. 

Iritis,  399. 

Irrational  conduct,  xiv,  414. 

Irritabilty,  62,  68,  71,  78,  79,  81, 
102,  205,  207,  220,  235,  239, 
243,  249,  267,  268,  269,  282, 
288,  290,  292,  293,  296,  328, 
329,  332,  335,  336,  344,  353, 
371,  373,  389,  416,  419,  431, 
445,  628,  629,  631,  634,  637, 
638. 

Isolation,  29,  103,  105,  109,  311, 
334. 

Italian  race,  12. 

Jacksonian  epilepsy,  345,  386,  417, 
438. 


INDEX  OF  SUBJECTS 


667 


JaUs,  186. 
Jaundice,  68,  80. 
Jealous  paranoiacs,  265. 
Jealousy,   ideas  of,   see  Ideas  of 

jealousy. 
Jendrassik  reinforcement,  81. 
Jerking,  muscular,  318,  441. 
Jewish  race,  12. 
Joy,  see  Euphoria. 
Judgment,  23,  24,  25,  2G,  28,  98, 

127,  206,  216,  220,  268,  319, 

320,  328,  335,  374,  445,  631. 
disorders  of,   54-60,    182,   203, 

215,  218,  221,  277,  387,  630. 
Justices  of  the  peace,  191. 
Juvenile  delinquents,  186. 
Juvenile  general  paralysis,  78,  400. 

Kent-Rosanoff  test,  98,  547-620. 
Ividney  lesions,  346,  361,  385,  395. 

See    also    Albuminuria    and 

Nephritis. 
Ivindness,  371. 
Kleptomania,  321. 
Knee  jerks,  81,  300,  366,  382,  388, 

441,  446,  630. 
Korsakoff's    psychosis,    351-354, 

626,  632,  633. 

Lactation,  10. 

Lacunar   softenings,    see   Slit-like 

defects. 
Lamentations,  281,  295,  297,  298. 
Lancinating  paroxysms,  338,  371, 

388. 
Lange's  colloidal  gold  test,  89,  368, 

391,  452,  455-458. 
Language  ability,  98. 
Lassitude,  63,  67,  337,  371. 
Latent   content   of  dreams,    128, 

129,  133,  137. 
Lateral  sclerosis,  388. 
Laughter,  232,  474,  475,  629,  637. 
Lavage,  gastric,  112,  428. 
Lead  poisoning,  457,  626,  633. 


Learning,  98,  99. 
Legal  competence,  182. 
Legal  responsibility,  183. 
Legislation  against  alcohol,  175. 
Legislation  against  habit-forming 

drugs,  177. 
Leucocytosis,  438. 
Libido,  infantile  fixation  of,  124. 
Liepmann's  phenomenon,  30. 
Lightning  pains,  338,  371,  388. 
Listlessness,  277,  631. 
Litigious  paranoiacs,  265. 
Liver  lesions,  338,  339,  340,  346, 

385,  395,  400. 
Loafing,  315. 
Loathing,  122. 
Local  option,  175,  177. 
Logic,  60,  67,  263,  264,  270,  637. 
Logical  memory  test,  621,  622. 
Logical  thmking,  137-139. 
Logorrhoea,  271,  281,  282,  291. 
Long  or  medullary  arterioles,  405, 

407,  408,  409. 
Loquaciousness,  293,  387. 
Loss  of  employment,  10,  119,  213. 
Love,  123,  124,  131,  132,  140,  141. 
Love  affairs,  11. 
Lucidity,  41,  62,  82,  206,  210,  211, 

230,  238,  243,  244,  248,  264, 

268,  271,  277,  280,  291,  293, 

324,  332,  336,  349,  354,  359, 

363,  414,  421,  425,  430,  448. 
Lumbar  puncture,  88,  89,  286,  364, 

390,  401,  411,  449,  468,  630. 
Luminal  in  epilepsy,  213,  214. 
Lunacy,  xiv. 
Lying,  pathological,  216,  221,  269, 

317. 
Lymphocytosis,  89,  367,  368,  390. 

See  also  Cell  count. 
Lymphoid  cells,  367. 
Lypemania,  see  Melancholia. 

Macrocephaly,  197. 
Macroscopic  lesions,  392. 


668 


INDEX  OF  SUBJECTS 


Make-up,  psychic,  79,  90,  96,  98, 
166,  167,  285,  303,  638,  639. 
See  also  Personality. 
Maladjustment,  sexual,  121. 
social,    see    Social    maladjust- 
ment. 
Malaise,  74. 
Malaria,  634. 
Male  sex,  see  Sex. 
Malformations,  cranial,  80,  197. 
Maliciousness,  220. 
MaUngering,    192,   308-314.     See 

also  Simulation. 
Mania,  25,  35,  48,  50,  51,  52,  60, 
68,  69,  71,  102,  236,  267-276, 
277,  279,  280,  282,  286,  287, 
288,  289,  361,  387,  444. 
chronic,  290,  291. 
confused,  267,  275,  276. 
delusional,  267,  271-275. 
epileptic,  211. 
recurrent,  283. 
simple,  267-271. 
transitory,  211. 
Maniacal  drunkenness,  333,  334. 
Manic-depressive  psychoses,  6,  9, 
12,  14,  16,  44,  86,  99,  108,  115, 
118,  174,  192,  193,  201,  211, 
227,  243,  245,  2.59,  260,  267- 
291,  294,  327,  387,  390,  448, 
627,  628,  632,  633,  635,  639, 
640. 
circular  types,  283,  627,  635. 
course  of,  276,  280,  282. 
depressed  types,  277,  293,  627, 

635. 
diagnosis,  285,  286. 
duration,  276,  280. 
etiology,  284. 
homogeneity  of,  276,  286. 
manic  types,  267,  283,  627,  635. 
mixed  types,  281,  282,  627,  635. 
prognosis,  276,  280,  282,  284. 
treatment,  276,  281,  282,  289. 
Manic  stupor,  281,  627,  635. 


Manifest  content  of  dreams,  see 
Dreams,  manifest  content  of. 
Mannerisms,  237,  242,  637. 
Marasmus,  378. 
Marital  condition,  1,  15,  79. 
Marital  infelicity,  11. 
Marital  infidelity,  11. 
Marriage  restriction,  171. 
Masked  epilepsy,  210. 
Masochism,  224,  225. 
Masturbation,  79,  122,  135,  224, 

319,  366. 
Maturity,  measures  in   terms  of, 

95. 
Measurements,    mental,    88,    92- 

100,  202. 
Measuring  scales  of  intelligence, 

90.  95,  96. 
Mechanical  restraint,  103,  347. 
Mechanisms,  etiologic,  80,  314. 
of  delusions,  66,  127. 
of  dreams,  127,  135. 
of  obsessions,  127. 
of  phobias,  127. 

psychic,  66,  100,  124,  137,  139, 
300,  302,  306,  315,  318. 
Median,  93. 

Medical  consultations,  91,  93. 
Medication,  357. 

hypodermic,  106,  107,  214,  360. 
in  delirium  tremens,  348. 
in  epilepsy,  213. 
in  excitement,  103,  105. 
intracranial,  402. 
intraspinal,  365,  401,  402. 
intravenous,  401. 
rectal,  105,  106,  214,  404. 
Medico-legal  questions,  181,  208, 

315,  387,  389. 
Mediums,  writing,  37. 
Medulla,  lesions  of,  409. 
Medullary  or  long  arterioles,  405, 

407,  408,  409. 
Megalomaniacal  syndromes,  245, 
246. 


INDEX  OF  SUBJECTS 


669 


Melancholia,  28,  38,  50,  58,  G3,  65, 
06,  67,  103,  110,  230,  267,  379. 
See  also  Involutional    melan- 
cholia, 
agitated,  292. 

anxious,  292,  295,  296,  298. 
delusional,  295,  296. 
stuporous,  294,  295. 
wasting  in,  298. 
Melancholy      ideas,     see     Ideas, 

melancholy. 
Memory,  42-48,  62,  83,  86,  92,  95, 
98,  182,  199,  200,  230,  231, 
268,  329,  335,  351-354,  366, 
372,  381,  386,  389,  415,  416, 
418,  444,  628,  629,  630,  631, 
633,  637. 
hallucinations  of,  46,  47,  352, 

445. 
illusions  of,  46,  47,  352,  445. 
Mendacity,  78,  79. 
Mendelian  theory  of  heredity,  3. 
Meningitis,  38,  78,  345,  391,  454, 

458,  626,  632. 
Meningo-encephalitis,  38,  383. 
Menstrual  function,  68,  80,  271, 

285,  294,  296. 
Mental  age,  95,  197,  198,  480. 
Mental  alienation,  xiv,  52. 
Mental  automatism,  see  Automa- 
tism, mental. 
Mental  capacity,  83,  90,  91. 
Mental  confusion,  43,  44,  49,  52, 
74,   251,   255,   286,   422^428, 
441. 
delirious  form,  422,  423,  425. 
hyperacute  form,  423,  426,  427. 
simple  form,  422,  423-425. 
stuporous  form,  20,  423,  426. 
Mental  content,  total,  120. 
Mental   deficiency,    96,    99,    139, 
148,  172,  173,  174,  190,  192, 
212,  215,  216,  227,  300.    See 
also  Arrests  of  development 
and  Feeble-mindedness. 


Mental  deterioration,  25,  60,  99, 
114,  200,  202,  219,  220,  227, 
229,  234,  242,  243,  246,  253, 
257,  259,  261,  263,  264,  266, 
267,  286,  291,  293,  329,  335, 
338,  339,  349,  354,  372,  379, 
383,  386,  390,  402,  408,  409, 
418,  438,  443,  445,  448,  629, 
637,  640.    See  also  Dementia. 

Mental  development,  78,  90. 
normal  course  of,  474,  475. 

Mental  examination,  59,  81-86, 
202. 

Mental  hygiene,  v,  148,  155,  165, 
180,  258. 

Mental  infirmity,  xiii,  xiv,  11. 

Mental  measurements,  88,  92-100, 
202. 

Mental  mechanisms,  see  Mechan- 
isms. 

Mental  status,  92. 

Mental  tension,  629. 

Mercury,  365,  368. 

Mesoblastic  neuro-syphilis,  see 
Cerebral  arteriosclerosis  and 
Cerebral  syphilis. 

Metabolism,  64. 

Metaphysical  ideas,  57. 

"  Metasyphilitic  "  disorders,  396. 

Methods  of  examination,  26,  80- 
87. 

Microcephaly,  197. 

Microscopic  lesions,  392-394,  411. 

Middle  cerebral  artery,  409. 

Middle  ear  disease,  30,  438. 

Migraine,  77. 

Miliary  plaques,  448. 

Military  recruits,  see  Recruits, 
military. 

Milk  diet,  348,  430. 

Mischievousness,  269. 

Misdemeanors,  387. 

Miserliness,  78,  79. 

Mistakes  of  identity,  21,  250,  272, 
296,  415,  632 


670 


INDEX  OF  SUBJECTS 


Mocking,  269. 

Monomania,  55.  See  also  Paranoia. 
Monoplegia,  233,  381,  409,  438. 
Monotony,  57,  211,  236,  240,  243, 

295,  420. 
Mood,  62,  205,  277,  282,  371,  372, 

445.    See  also  Affectivity. 
Moral  imbecility,  203,  220. 
Moral  insanity,  220. 
Morality,  aesthetic,  316,  317. 

imposed,  316,  317. 

prudent,  316,  317. 

pure,  316,  317. 

sexual,  123. 
Moral  sense,  122,  215,   219,  220, 

269,  332,  336,  359,  374. 
Moronism,  195,  197,  198,  639.- 
Morphine,  8,  105,  194,  357. 
Morphinism,  119,  357-363. 

etiology,  356. 

evolution,  358-351. 

prognosis,  363. 

symptoms  of  abstinence  in,  330- 
361. 

treatment,  361-363. 
Motility,  disorders  of,  233,  372. 
Motivated   forgetting,    124,    125, 

126,  257. 
Motives,  concealed,  304,  309,  315, 
318. 

conscious,  310. 

ethical,  141. 

iUicit,  304,  305,  315. 

unconscious,  120,  310. 
Motor  aphasia,  409. 
Motor  hallucinations,  see  Halluci- 
nations, motor. 
Motor  reactions,  68. 
Moulding   for   presentability    (in 

dreams),  135,  136. 
Multiple  sclerosis,  375,  382,  437, 

438,  457,  626,  632. 
Murder,  26,  250,  336,  389. 
Muscular  atony,  318. 
Muscular  atrophy,  300,  374,  384. 


Muscular  coordination,  7,  81. 
Muscular  incoordination,  374,  375, 

376,  409. 
Muscular  jerking,  318,  441. 
Muscular  rigidity,  388,  441. 
Muscular  twitching,  318,  375,  441. 
Muscular  weakness,  337,  360,  371, 

374,  408,  416,  446. 
Musical  ability,  200. 
Mutism,  37,  73,  81,  238,  240,  241, 

243,  278,  300,  306,  307,  309, 

312,  635. 
Mydriasis,  233,  234,  377. 
Myocarditis,  339,  385. 
Myosis,  337,  377,  430,  446. 
Mystic  delirium,  68,  429.- 
Mystic  ideas,  210,  245,  636. 
Mystics-paranoiacs,  265. 
Mythomania,  221. 
Myxoedema,  431-433. 

Nails,  in  hypothyroidism,  432. 
Nakedness,  dreams  of,  130,  131. 
Narcotics,  8,  355. 
National  Army,  8,  192,  216,  218, 

305,  347. 
National  Committee  for  Mental 

Hygiene,  148,  173,  190,  212, 

218,  311. 
Native  insane,  17,  18. 
Nausea,  318,  638. 
Necrophilia,  224,  226. 
Negation,  ideas  of,   see  Ideas  of 

negation. 
Negative  automatism,  72,  73. 
Negativism,  72,  73,  82,  109,  232, 

233,  238,  239,  241,  243,  254, 

258,  295,  296,  374,  636,  637. 
Negligence,  235,  280,  335. 
Negro  race,  12,  13,  552,  553. 
Neologisms,  33,  135,  244,  247,  549, 

550,  551,  552. 
Nephritis,  91,  339,  346,  408.    See 

also  Albuminuria  and  Kidney 

lesions. 


INDEX  OF  SUBJECTS 


671 


Nerve  cells,  261,  330,  334,  339, 
346,  384,  392,  394,  411,  427, 
439,  448. 

Nerve  fibers,  339,  346,  393,  394, 
439,  448. 

"Nervous  breakdown,"  303,  319. 

"Nervous  prostration,"  77,  319. 

Neuralgia,  364,  366. 

Neurasthenia,  xiv,      77,  88,   258, 
318-319,  371,  627,  638. 
sexual,  318,  319. 
splanchnic,  318. 

Neuroglia,  394. 

Neuropathic  constitution,  5,  78, 
179,  195,  215,  303,  327,  356, 
397. 

Neuropsychiatry,  in  war,  see  Na- 
tional Army,  War  neuroses, 
and  World  War. 

Neuroses,  see  Psychoneuroses. 

Neuro-syphilis,  see  Cerebral  arte- 
riosclerosis, Cerebral  syphilis, 
and  General  paralysis. 

Nightmares,  280,  337,  342,  431. 

Nissl's  corpuscles,  393. 

Noctm-nal  enuresis,  122. 

Noguchi's  butyric  acid  test,  88, 
391,  459. 

Nomadism,  216,  227,  228. 

Non-specific  reactions,  548,  551, 
552,  553. 

Normal  course  of  development, 
474-475. 

Normal  curves  of  distribution,  93, 
100. 

Normal  reactions,  548,  549,  551, 
552,  603. 

Nose,  abnormalities  of,  91. 

Nosophobia,  323. 

"Not  insane,"  172,  627,  639,  640. 

Nulliplex  inheritance,  4. 

Nursing,  114,  402,  403. 

Nutrition,  general,  64,  69,  80,  234, 
241,  256,  271,  294,  345,  360, 
362,  372,  377,  378,  388,  431. 


Nystagmus,  81. 

Obscene  language,  32,  37,  271,  389. 
Obsessions,  65,  121,  141,  221,  319- 
326,  638. 

homicidal,  321,  322. 

impulsive,  225,  320,  321. 

inhibiting,  320,  322. 

inteUectual,  320,  321. 

mechanisms  of,  127. 

suicidal,  321,  322. 
Occlusion  of  cerebral  vessels,  408. 
Occupation,  1,  15,  212,  227,  356, 

400,  436. 
Occupation  delirium,  211,  343. 
Occupation  dreams,  337,  415. 
Occupation,  therapeutic,  114,  261. 
Oculo-motor  paralysis,  438. 
(Edema,  234,  360,  423,  430. 
GEdipus  legend,  132. 
Olfactory  hallucinations,  see  Hal- 
lucinations, olfactory. 
Ohguria,  234,  430. 
Omens,  126. 

Onanism,  see  Masturbation. 
Onomatomania,  321. 
Onset  of  psychoses,  54,  58,  79,  80, 
231,  234,  236,  237,  251,  255, 
262,  277,  378,  389,  423,  427, 
434,  444. 
Operations,   surgical,  see  Surgical 

operations. 
Ophthalmoplegia,  376. 
Ophthalmoscopic  examination,  81. 
Opium,  8,  194,  355,  357,  626,  633. 

in  excitement,  105. 

in  involutional  melanchoha,  299. 
Opposites  test,  621,  623. 
Optic  nerve  atrophy,  360,  383. 
Optic  neuritis,  438. 
Optimism,  68,  269,  371. 
Organic  cerebral  affections,  437- 

442,  470,  631,  632,  637. 
Organic  crises,  378. 
Organic  psychoses,  139,  194. 


672 


INDEX  OF  SUBJECTS 


Orgasm,  premature,  319. 

Orientation,  40,  83,  230,  268,  273, 
329,  349,  359,  373,  380,  389, 
628,  631,  636.  See  also  Dis- 
orientation. 

Orientation,  allopsychic,  40,  342, 
424. 
autopsychic,  40,  211,  252,  342, 

424. 
of  personality,  40. 
of  place,  40,  353,  366,  415. 
of  time,  40, 199,  291,  353,  366, 
415,  424. 

Otitis  media,  30,  438. 

Outdoor  life,  213. 

Out-patient  clinics,  119,  147,  153, 
155. 

Over-determination,  136. 

Overseers  of  the  poor,  191. 

Overwork,  119,  256,  257,  443,  634. 

Pachymeningitis  hemorrhagica  in- 
terna, 330,  392. 
Pack,  wet,  104. 
Pain,  65,  80,  309,  318,  353,  371, 

417. 
Pain,  psychic,  see  Psychic  pain. 
Painful  hallucinations,  see  Hallu- 
cinations, painful. 
Pallor,  63,  65,  80,  207,  295,  360, 

361. 
Palpitation,  295,  435,  638. 
Pandy's  phenol  test,  89,  391,  459. 
Panophobia,  320,  323. 
Paresthesia,  344,  353,  411,  638. 
Paraldehyde,  106,  348. 
Paralysis  agitans,  626,  632. 
Paralysis,  121;  203,  300,  303,  307, 
309,  312,  323,  331,  332,  333, 
364,  381,  382,  385,  410,  411, 
418,  629. 
brachial,  409. 
facial,  344,  366,  381,409.' 
oculo-motor,  438. 
of  attention,  48. 


Paralysis  of  the  will,  70. 

psychic,  xiii,  49,  67,  70,  286, 287, 

295,  424,  426,  431. 
psychomotor,  66. 
Paralytic  dementia,  370. 
Paranoia,  6,  28,  52,  58,  193,  218, 

229,  244,  260,  262-266,  327, 

350,  448,  627,  637,  639. 
Paranoia  litigans,  265. 
Paranoia  originaire,  60,  262. 
Paranoia  querulens,  265. 
Paranoiacs,  amorous,  265. 
filial,  265. 

hypochondriacal,  265. 
-inventors,  265. 
jealous,  265. 
-mystics,  265. 
Paranoid  dementia,  229,  244,  246, 

255,  266. 
Paranoid  personality,  216,  218. 
Paranoid  state,  presenile,  447,  625, 

629. 
Paraphasia,  344,  473. 
"  Parasyphilitic  "  disorders,  396. 
Parenchymatous  neuro-syphilis, 

see  General  paralysis. 
Parental  alcoholism,  195,  196. 
Parental  authority,  124. 
Parental  syphilis,  196. 
Paresis,  see  General  paralysis. 
Parole,  77,  117,  154,  173,  187,  188. 
Partial  dissociation,  552. 
Particles  of  speech,  549,  551,  552. 
Part-whole  test,  621,  624. 
Passivity,  57,  81. 
Patellar  reflex,  see  Knee  jerks. 
Pathological  anatomy,   334,  338, 

339,  346,  365,  367,  392-394, 

409,  410,  427,  439,  448. 
Pathological      drunkenness,      see 

Drunkenness. 
Pathological  lying,  216,  221,  269, 

317. 
Pathological  reactions,   548,   549, 

552. 


INDEX  OF  SUBJECTS 


673 


Pathological     suggestibility,     see 

Suggestibility. 
Pauperism,  78,  177,  190.     See  also 

Dependency. 
Pederasty,  226. 
PeUagra,  441,  626,  633. 
Penal  institutions,  v,  78,  186,  187, 

192,  212,  220. 
Penitentiaries,  186. 
Perception,  19,  67,  70,  85,  98,  237, 
238,  239,  277,  373,  444. 
imaginary,  see  Hallucinations, 
inaccurate,  see  Illusions, 
insufficiency  of,  19,  20,  49,  278, 
286,  287,  332,  422,  424. 
Periencephalo-meningitis,  370. 
Periodic  psychoses,  283,  284. 
Peripheral  hallucinations,  29,  30. 
Peripheral  nerve  lesions,  394. 
Perivascular  gliosis,  407. 
Perivascular  infiltration,  367,  393. 
Perplexity,  257,  441. 
Persecution,  ideas  of,  see  Ideas  of 

persecution. 
Perseverance,  216,  221. 
Perseveration,  329,  550,  552. 
Personal  history,  see  History,  per- 
sonal. 
Personality,  40,  74,  84,  95,  97,  262, 
301,  342,  366,  631,  638,  639. 
autistic  or  shut-in,  255,  259,  285, 

636. 
disaggregation  of,  37,  54,  245. 
disorders  of,  35,  37,  73-75,  215. 
doubling  of,  301. 
epileptic,  205. 

hysterical,  303,  312,  316,  317. 
inadequate,  216,  258. 
of  physician,  113. 
orientation  of,  40. 
paranoid,  216,  218. 
reduplication  of,  58,  74,  75,  320. 
shut-in  or  autistic,  255,  259,  285, 

636. 
splitting  of,  301,  315. 


Personality,  transformation  of,  74, 
75,  249,  250,  255,  320,  425. 

Perspiration,  361,  426,  435,  436, 
638. 

Persuasion,  303,  310,  311. 

Perversioa  of  psychic  functions, 
xiii. 

Perversion  of  the  will,  73. 

Perversion,  sexual,  78,  79,  122, 
124,  223,  224,  639. 

Pessimism,  249,  269,  277,  285,  292, 
371. 

Phantasy  thinking,  137-139. 

Pharmaco-psychology,  experimen- 
tal, 99. 

Phenol  test,  Pandy's,  89,  391,  459. 

Phlegmons,  361. 

Phobias,  121,  127,  322,  323,  638. 
mechanisms  of,  127. 

Phonemes,  31,  34,  249. 

Physical  causes,  10,  78,  303,  304. 

Physical  examination,  80, 140, 202. 

Physician,  personality  of,  113. 

Physician's  certificate  of  insanity, 
102. 

Physiognomy,  196,  238,  280,  432. 
See  also  Expression,  facial. 

Pia-arachnoid,  lesions  of,  365,  392, 
393. 

Pial  infiltration,  367,  393. 

Picric  acid,  403. 

Pimps,  357. 

Pithiatism,  302. 

Pituitary  gland,  634. 

Planlessness,  216. 

Plantar  reflex,  81,  337,  366,  382, 
388,  441. 

Plaques,  miliary,  448. 

Plasma  cells,  367,  393. 

Plea  of  insanity,  185. 

Pleasing  hallucinations,  see  Hallu- 
cinations, pleasing. 

Pledge  of  abstinence,  114. 

Pleocytosis,  89,  367,  368,  390. 
See  also  Cell  coimt. 


674 


INDEX  OF  SUBJECTS 


Pneumococcus  infection,  346. 
Pneumonia,   214,   276,   299,   345, 

347,  354,  385,  394,  403,  427, 

430,  448. 
Point  scale  of  intelligence,  96. 
Police,  188,  191,  192,  215. 
Pollution,  sexual,  122. 
Polyneuritic  psychosis,  7,  43,  47, 

194,  342,  351-354,  626,  632, 

633,  634. 
course,  354, 
diagnosis,  354. 
etiology,  351. 
prognosis,  354. 
symptoms,  351-353. 
treatment,  354. 
Polyneuritis,  338,  351,  352,  353, 

354,  632. 
Polyuria,  68,  234,  378,  430. 
Pons,  lesions  of,  409. 
Poorhouse,  203. 
Possession,  ideas  of,  see  Ideas  of 

possession. 
Post-epileptic  stupor,  207,  210. 
Posterior  cerebral  artery,  409. 
Post-febrile  psychoses,  634. 
Post-infectious  psychoses,  634, 635. 
Post  mortem,  see  Autopsy. 
Post-traumatic    mental    enfeeble- 

meno,     625,     628.     See    also 
•     Traumatic  dementia. 
Poverty,  119,  146,  216. 
Predisposition,     neuropathic,     9, 

118,  331,  340. 
Pregnancy,  10,  256,  285. 
Premature  birth,  78. 
Premature  orgasm,  319. 
Premature  senility,  443. 
Premeditation,  26. 
Presbyophrenic  type  of  senile  de- 
mentia, 625,  628. 
Presenile  paranoid  state,  447,  625, 

629. 
Presentiments,  67,  371. 
Pressure  sores,  384,  390,  402. 


Prevalence  of  mental  disorders,  17, 

18,  160,  180,  190. 
Prevention  of  epilepsy,  212. 
Prevention   of   mental   disorders, 

159,  165,  180,  401. 
Prevention   of  recurrencies,    118, 

119,  154,  289. 
Previous  attacks,  76,  80. 
Primary    mental    confusion,    see 

Mental  confusion. 
Primary  syphilis,  365,  396,  401. 
Prisons,  186,  192,  220. 
Probability  integral,  93. 
Probable  Error,  93,  94. 
Prodromata,  236,  243,  245,  267, 

277,  289,  292,  342,  348,  370, 

371,  422. 
Profane  language,  271. 
Prognosis,  28,  33,  35,  37,  44,  54, 

59,  76,  86,  158,  202,  245,  251, 

252,  253,  266,  276,  280,  282, 

284,  294,  298,  338,  344,  345, 

350,  354,  361,  363,  369,  389, 

390,  412,  421,  426,  430,  448. 
Progressive  amnesia,  see  Amnesia, 

progressive. 
Prohibition,  175,  176. 
Projection  centers,  lesions  of,  386. 
Prolixity,  271,  281. 
Prophylaxis    in   psychiatry,    118, 

119,  154,  159,  165-180,  212, 

257,  401. 
Prophylaxis  of  syphilis,  168,  178. 
Propriety,  sense  of,  269. 
Prostitution,  78,  79,  168,  186,  200, 

215,  224,  357,  401. 
Prostitution   and   mental   defect, 

168-170,  185. 
Prostitution,  control  of,  168. 
Prostration,  361,  423,  634. 
Prudent  morality,  316,  317. 
Pseudo-hermaphroditism,  226. 
Psendologia  phantastica,  221. 
Pseudo-reminiscences,     47,     272, 

352,  354,  381,  416,  445. 


INDEX  OF  SUBJECTS 


675 


Psychasthenia,  77,  258,  319-326, 
371,  627,  638. 

Psychiatric  social  worker,  149-150. 
in  courts,  150. 
in  industries,  150. 
in  reformatories,  150. 
in  schools,  150. 
in  social  agencies,  150. 
practice  work,  149. 
qualifications,  149. 
training,  149. 

Psychiatric  statistics,  see  Statis- 
tics, psychiatric. 

Psychiatry,  xiii. 

Psychic  catharsis,  145. 

Psychic  causes,  10,  303,  304. 

Psychic  determinism,  120. 

Psychic  disaggregation,  see  Dis- 
aggregation, psychic. 

Psychic  functions,  per\^ersion  of, 
xiii. 

Psychic  hallucinations,  see  Hallu- 
cinations, psychic. 

Psj'chic  infirmity,  xiii,  xiv,  11. 

Psychic  inhibition,  see  Inhibition, 
psychic. 

Psychic  interference,  73. 

Psychic  make-up,  see  Make-up, 
psychic;  also  Personality. 

Psychic  mechanisms,  see  Mechan- 
isms. 

Psychic  pain,  58,  63,  65,  66,  67, 
108,  236,  278,  280,  286,  292, 
293,  295,  297,  298,  299,  388, 
447,  448.  See  also  Depression 
and  Sadness. 

Psychic  paralysis,  see  Paralysis, 
psychic. 

Psychoanalysis,  117,  120-145,  306. 
technique    of,    98,     128,     139- 
145. 

Psychogenic  factors,  100. 

Psychogenic  disorders,  85. 

Psychological  group  tests,  97,  621- 
624. 


Psychological  research,  95,  96. 

Psychology,  applications  of,  92. 
differential,  100. 
educational,  99. 

Psychometry,  287,  373,  431,  444, 
639.  *See  also  Measurements, 
mental. 

Psychomotor  paralysis,  66. 

Psychoneuroses,  6,  11,  12,  77,  113, 
117,  124,  132,  139,  141,  145, 
192,  193,  215,  216,  300-326, 
357,  627,  637,  638,  639. 

Psychopathic  states,  see  Constitu- 
tional psychopathic  states; 
also  Constitutional  inferiority. 

Psychopathic  wards  in  general 
hospitals,  181. 

Psychopathology,  experimental, 
99. 

Psychopathology  of  everyday  life, 
124. 

Psychopathy,  sexual,  216,  223- 
227. 

Psycho-sensory  disorders,  see  Hal- 
lucinations and  Illusions. 

Psychoses,  xiii. 

Psychotherapy,  112-117,  120,  140, 
147,  201,  266,  281. 

Ptosis,  337,  366. 

Puberty,  122,  124,  229,  256,  435. 

Puerilism,  437. 

Puerperal  state,  427. 

Pulse,  63,  65,  69,  80,  81,  234,  271, 
276,  278,  295,  332,  345,  361, 
385,  408,  423,  426,  432,  433, 
436,  438,  631. 

Pimishment,  183. 

deterrent  effect  of,  183, 187,  219. 

Pupils,  examination  of,  81. 
in  cerebral  syphilis,  366. 
in  chronic  alcoholism,  337. 
in  dementia  preecox,  233. 
in  depression,  65,  295. 
in  general  paralysis,  372,  376- 
377,  381. 


676 


INDEX  OF  SUBJECTS 


Pupils,    in    morphine    addiction, 
360. 

in   primary    mental    confusion, 
426. 

in  senile  dementia,  446. 

in  uraemic  delirium,  430. 
Pure  morality,  316,  317. 
Purgatives,  430. 
Pyramidal  tract,  lesions  of  382. 
Pyromania,  187,  321. 
Pyrosis,  338. 

Quantitative  methods,  92,  98. 
Quarreling,  235,  351. 

Race,  1,  12,  355,  356. 
Rambling  speech,  82,  269,  273. 
Rape,  223,  383,  387,  389,  445. 
Rapport,  114,  140,  477. 
Raptus  melancholicus,  295. 
Rational  thinking,  137-139. 
Reactions,  25,  26,  41,  55,  65,  66, 
70-73,  230,  231,  232,  236,  237, 
241,  244,  245,  248,  251,  255, 
257,  263,  270,  278,  295,  296, 
298,  359,  363,  374,  380,  424, 
429,  447. 
automatic,  66,  67,  68,  70,  72, 

208,  232,  296,  445. 
automatic,  negative,  71. 
automatic,  positive,  71. 
common,  548,  551,  552,  553. 
contrary,  73. 

doubtful,  548,  551,  552,  553. 
impulsive,  26,  41,  68,  71,  102, 
205,  236,  254,  267,  270,  288, 
332,  374,  447. 
mdividual,   98,   548,   549,   551, 

552,  553. 
motor,  68. 

non-specific,  548,  551,  552,  553. 
normal,  548,  549,  551,  552,  603. 
pathological,  548,  549,  552. 
sound,  549,  551,  552. 
specific,  551,  552,  553. 


Reactions,  unclassified,  550,  551, 

552. 
violent,  see  Violent  reactions, 
voluntarj^  70,  231,  238. 
Reaction  time,  49,  99,  548. 
Reaction  types,  257,  259,  301,  547. 
Reactivation   of   immune   serum, 

460. 
Reading  tests,  85,  375. 
Re-admissions  to  institutions,  118. 
Realistic  thinking,  137-139. 
Reasoning  insanity,  see  Paranoia. 
Recessive  condition,  3,  5,  327. 
Recovery,  64,  114,  118,  154,  158, 

159,  201,  202,  242,  252,  253, 

255,  267,  268,  271,  273,  276, 

280,  281,  290,  291,  293,  294, 

298,  305,  306,  308,  345,  350, 

354,  363,  365,  338,  369,  390, 

409,  412,  414,  426,  436,  640. 
Recruits,  military,  97,   192,  216, 

347,  436. 
Rectal  feeding,  214. 
Rectal  medication,  105,  106,  214, 

404. 
Recurrency,    103,    118,    159,   201, 

252,  267,  282,  286,  289,  305, 

350,  363,  635. 
prevention  of,  118, 119, 154,  289. 
Recurrent  depression,  283. 
Recurrent  mania,  283. 
Recurrent  psj^choses,  54,  62,  201, 

267. 
Recurrent  vomiting,  78. 
Reduplication  of  personality,  58, 

74,  75,  320. 
Re-education,  99,  114,  312. 
Reference,  ideas  of,  258,  636. 
Reflex  hallucinations,  29. 
Reflexes,  432. 

cutaneous,  337,  344,  382. 
plantar,  81,  337,  366,  382,  388, 

441. 
pupillary,  81,  233,  300,  366,  376, 

377. 


INDEX  OF  SUBJECTS 


677 


Reflexes,   tendon,    81,   233,   279, 
300,  337,  344,  353,  360,  366, 
382,  388,  441,  446,  630. 
Reformatories,  150,  185,  212. 
Refractory    hysterics,    308,    311, 

312,  317. 
Refusal  of  food,  35,  58,  66,  101, 
109-112,  238,  241,  243,  261, 
298,  349,  388,  402,  428,  441. 
absolute,  109. 
complete,  109. 
partial,  109. 
relative,  109. 
treatment,  109-112. 
Religious  influences,  114. 
Religious  preoccupation,  78,  79. 
Religious  scruples,  322,  323. 
Remissions,    118,   252,    253,    254, 
276,  280,  286,  377,  382,  386, 
387,  390,  432,  448. 
Remorse,  221. 

Renal    lesions,    see    Albuminuria, 
Kidney  lesions,  and  Nephritis. 
Repetition  of  thought,  32. 
Repressed    wish,    128,    130,    315, 

638. 
Repression,    121,    122,    123,    124, 

127,  128,  131,  301,  302. 
Reproduction,     amnesia    of,     see 

Amnesia  of  reproduction. 
Research,  psychological,  95,  96. 

sociological,  150,  154. 
Resignation,  63. 

Resistance,  psychic,  140,  142,  144. 
Resistiveness,  81,  241,  243,  629. 
Respect,  140. 

Respiration,  80,  271,  294,  295, 361, 
385,  426,  433. 
in  anger,  67. 
in  depression,  64,  65. 
in  euphoria  or  joy,  69. 
Responsibility,  criminal,  xiv,  181, 
183-185. 
legal  conception  of,  183. 
scientific  conception  of,  184. 


Rest  in  bed,  103,  105,  109,  276, 

281,  299,  307,  347,  354,  412, 
428,  436. 

Restlessness,  104,  337,  360,  367, 
414,  420,  435,  438,  441,  628, 
635.     See  also  Excitement. 

Restraint,  mechanical,  103,  347. 

Restriction  of  marriage,  171. 

Retardation  in  school,  77,  79,  148, 
191,  192,  303. 

Retardation,  psychomotor,  92,  99, 
319,  G35. 

Retention,  354,  628,  629,  632. 
See  also  Memory. 

Retention  tests,  84. 

Reticence,  27,  259. 

Retribution,  183,  184. 

Retrobulbar  neuritis,  337. 

Retrograde  amnesia,  see  Amnesia, 
retrograde. 

Retrogressive  amnesia,  44. 

Retrospective  falsifications,  54. 
See  also  Fabrications,  Hallu- 
cinations of  memory.  Illu- 
sions of  memory,  and  Pseudo- 
reminiscences. 

Revenge,  183. 

Reverses  in  business,  10,  79. 

Rigidity,  muscular,  388,  441. 

Romberg  sign,  81,  388. 

Ross-Jones  ammonium  sulphate 
test,  89,  391,  459. 

Ruin,  ideas  of,  see  Ideas  of  ruin. 

Rural  environment,  14,  401. 

Sadism,  224,  225. 

Sadness,  25,  58,  66,  197,  277,  278, 

282,  293,  294,  298,  324,  635. 
See  also  Depression  and  Psy- 
chic pain. 

Saline  injections,  428. 
Saliva,  68,  234. 
Salvarsan,  365,  368. 
Sanatorium,    78,    297,    324.     See 
also  Institutions. 


678 


INDEX  OF  SUBJECTS 


Sanitary  menace,  215. 
Scanning  speech,  81. 
Scaphocephaly,  197. 
Schizophrenia,  260,  636,  639. 
Schools,  V,  97,  150,  192,  202,  203. 
mental  cases  in,  see  Retardation 
in  school. 
Sclerosis,  combined,  382,  394. 

multiple,  see  Multiple  sclerosis. 
Scotoma,  central,  337. 
Scruples,  221,  269,  270. 
moral,  323. 
religious,  322,  323. 
Seclusion,  see  Isolation. 
Seclusiveness,  79,  259,  319,  63G. 
Secondary  syphilis,  364,  399. 
Sedatives,  105-107,  307,  348. 
Seduction,  122. 

Segregation,    164,    171-174,    184, 
202,  203,  204,  212. 
obstacles  to,  173. 
safeguards  in,  173. 
selection  for,  172. 
Seizures,  apoplectiform,  see  Apop- 
lectiform seizm-es. 
epileptiform,    see    Epileptiform 

seizures, 
hysteriform,     see     Hysteriform 
seizures. 
Sejunction,  39. 
Self-absorption,  319. 
Self-accusation,  ideas  of,  see  Ideas 

of  self -accusation. 
Selfishness,  61,  205,  220,  316,  328. 
Self-mutilations,  108. 
Self-observation,  141,  142. 
Seminal  emissions,  319. 
Senile  delirium,  447,  625,  629. 
Senile  dementia,  xiv,  13,  44,  45,  46, 
56,  61,  102,  269,  338,  345,  346, 
372,  391,    411,  425,  443-448, 
633. 
course,  448. 
diagnosis,  449. 
etiology,  443. 


Senile   dementia,   presbyophrenic 
type,  625,  628, 

prognosis,  448. 

symptoms,  444-447. 

treatment,  448. 
Senile  epilepsy,  447. 
Senile  psychoses,  12,  194,  625,  628. 
Senility,  369,  443. 

premature,  443. 
Senium  prcecox,  443. 
Sensitiveness,  63,  259,  296. 
Sensory  aphasia,  409. 
Septicemia,  634. 
Serological  tests,  79. 
Serum,  immune,  460. 

inactivation  of,  460. 

reactivation  of,  460. 
Sex,  1,  7,  9,  14,  15, 16, 121, 186, 203, 
300,  315,  319,  328,  400,  441. 

development  of,  122-124. 

immorality,  2, 148, 186, 191, 197. 

physical,  226. 

psychic,  226. 

theory  of,  121. 
Sexual  aim,  121,  123,  124. 

anaesthesia,  124. 

anomalies,  78,  79,  215. 

complexes,  121,  135,  302. 

end-pleasure,  122. 

fore-pleasure,  122,  124. 

frigidity,  124,  223,  224. 

inversion,  78,  79,  223,  224,  226. 

latencj^,  period  of,  122,  123. 

life,  76,  79,  179. 

maladjustment,  121. 

material,  in  dreams,  130,  133. 

neurasthenia,  318,  319. 

object,  121,  123,  124. 

perversion,  78,  79,  122, 124,  223, 

■     224,  639. 

pollution,  122. 

psychopathy,  216,  223-227. 

tension,  122. 
Sexuality,  adult,  122. 

infantile  121,  122,  124,  314. 


INDEX  OF  SUBJECTS 


679 


Shame,  122,  269. 

"Shell  shock,"  305. 

Shiftlessness,  216. 

Shirking,  2rxS,  315,  317. 

Shortness  of  breath,  435. 

Short  or  cortical  arterioles,  405, 
407,  408. 

Shrines,  114. 

Shut-in  personality,  see  Person- 
ality, shut-in. 

Shyness,  259. 

Sick  headache,  78,  303. 

Silliness,  631,  633,  637. 

Similar  heredity,  2,  78,  285,  327. 

Simplex  inheritance,  4. 

Simulation,  300,  303,  307,  308, 
313,  318,  417.  See  also  Ma- 
lingering. 

Sitiophobia,  see  Refusal  of  food. 

Skin  lesions,  432,  446. 

Skull,  fractures  of,  79,  413,  628. 
malformations,  80,  197. 

Slang,  359. 

Sleep,  40,  80,  129,  130,  210,  271, 
275,  279,  328,  331,  332,  333, 
337,  342,  345,  348,  350,  415, 
423,  426,  431,  446.  See  also 
Insomnia. 

Sleeplessness,  see  Insomnia. 

Slips  of  speech,  writing,  or  con- 
duct, 124. 

Slit-like  defects  in  cerebral  arterio- 
sclerosis, 410. 

Slouchy  bearing,  277. 

Slurring  speech,  81. 

Small-pox,  421,  634. 

Smell,  hallucinations  of,  see  Hallu- 
cinations, olfactory. 

Smoking,  356,  357. 

Snuffing,  357. 

Sociability,  79. 

Social  activities,  124. 

Social  case  work,  153,  155. 

Social  factors,  153,  339,  340. 

Social  history,  150,  202. 


Social  maladjustment,  145,  146, 
148,  156,  190,  191,  197,  200, 
215,  303,  639. 

Social  re-adjustment,  147,  148. 

Social  work,  77,  146-157,  212,  217, 
222. 

Social  worker,  psychiatric,  see 
Psychiatric  social  worker. 

Sociological  classification,  191. 

Sociological  department,  119. 
functions  of,  150. 
organization  of,  155. 

Sociology,  applied,  146-157. 

Softening,  cerebral,  391,  408,  629. 

Somatic  disorders,  65,  67,  119, 
233. 

Somnal,  106. 

Somnambulism,  207. 

Somnolence,  318,  342,  414,  431, 
446,  631. 

Sound  reactions,  549,  551,  552. 

Spastic  form  of  general  paralysis, 
388. 

Special  diagnostic  procedures,  88- 
91,  202,  449-624. 

Specific  reactions,  551,  552,  553. 

Speech  disorders,  81,  85,  328,  344, 
372,  375,  377,  381,  441. 

Speech  tests,  81,  375. 

Sphincter  control,  81,  197,  390, 
402. 

Spider  cells,  394. 

Spinal  cord  lesions,  384,  394. 

Spinal  forms  of  general  paralysis, 
388. 

Spinal  puncture,  see  Lumbar  punc- 
ture. 

Spirochete,  365.  See  also  Trepo- 
nema pallidum. 

Splanchnic  neurasthenia,  318 

Splitting  of  personality,  301,  315. 

Spontaneous  utterances,  81,  471. 

Spoon  feeding,  110. 

Sprees,  79. 

Staggering  gait,  438. 


680 


INDEX  OF  SUBJECTS 


Stammering,  376. 

Stanford  revision  of  Binet-Simon 
scale,  96,  198,  476-546. 

Statistics,  psychiatric,  2,  6,  8,  9, 
10,  12,  13,  14,  15,  16,  17,  87, 
118,  158,  160,  166,  185,  186, 
187,  191,  192,  212,  216,  255, 
285,  294,  397,  400,  401,  413, 
443. 

Stature,  259,  434. 

Status  epilepticus,  214. 

Stealing,  228,  269,  336. 

Stenographic  record,  82. 

Stereotypy,  71,  72,  85,  237,  238, 
243,  258,  261,  374,  637. 
of  attitudes,  72,  232,  238,  242, 

254. 
of  language,  see  Verbigeration. 
of    movements,    72,   232,    238, 
254. 

Sterilization,  171. 

Stigmata  of  degeneration,  ana- 
tomical, 197. 

Stock  of  ideas,  235,  335,  432,  445. 

Strabismus,  81,  337,  345,  366,  372, 
474. 

Stress,  11,  17,  292,  341,  427,  436. 

Stroke,  408. 

Strophanthus,  362. 

Strychnin,  214,  348. 

Stubbornness,  205,  218,  259. 

Stupor,  40,  50,  70,  74,  81,  82,  240, 
243,  253,  280,  292,  295,  414, 
416,  429,  430,  442,  627,  634, 
635,  637,  638. 
catatonic,  see  Catatonic  stupor, 
depressive,  74,  277,  280. 
manic,  281,  627,  635. 
post  epileptic,  207,  210. 

Stuporous  tnelancholia,  294,  295. 

Stuporous  mental  confusion,  20, 
423,  426. 

Stuttering,  81,  309,  344. 

Subconscious  complexes,  see  Com- 
plexes, subconscious. 


Subjective  complaints,  80. 
Sublimation,  122,  124. 
Substitution,  137,  257,  258. 
Suffocation,  261,  376. 
Suggestibility,  71,  232,  238,  239, 
241,  253,  274,  303,  312,  446, 
629,  632. 
Suggestion,     30,     108,     112-117, 
201,   281,  303,  312,  340,  344, 
352. 
Suicidal  obsession,  321,  322. 
Suicidal  tendencies,  58,  66,  77, 101, 
102,  105,  107-109,  208,  237, 
240,  243,  281,  295,  297,  298, 
299,  319,  329,  333,  367,  371, 
388,  402,  427,  441,  447. 
due  to  delusion,  108. 
due   to    disgust    for    existence, 

108. 
due  to  fixed  idea,  108. 
due  to  hallucination,  108. 
due  to  impulse,.  108. 
due  to  psychic  pain,  108. 
due  to  suggestion,  108. 
Suicide,  epidemics  of,  108, 
familial,  108,  296,  322. 
methods  of,  108,  297. 
prevention  of,  159. 
weapons  of,  108. 
Sulkiness,  431. 
Sulphonal,  106. 
Summary,  clinical,  86. 
Superficiality,  319. 
Supervision,   103,    105,    109,   173, 

202,  203,  204,  298,  299. 
Suppuration,  347. 
Surface  of  frequency,  94. 
Surgical  operations,  79,  91,  414, 

436,  438,  441. 
Surveys  of  mental  disorders,  148, 

190. 
Suspiciousness,  82,  201,  218,  249, 
258,  262,  263,  349,  447,  628, 
631,  633,  634,  636,  637. 
Swindling,  359,  387. 


INDEX  OF  SUBJECTS 


681 


Symbolic  reactions,  80. 
Symbolism,  in  dreams,  131,  133, 
134,  135,  144. 
in  folk  lore,  133. 
in  legends,  133. 
in  manners  of  speech,  133. 
in  myths,  133. 
in  proverbial  sayings,  133. 
in  wit,  133. 
sexual,  134,  135,  225. 
Sympathy,  see  Rapport,  and  Trans- 
ference. 
Symptoms  of  abstinence,  347,  356, 

360,  361. 
Syncope,  104. 

Syphilis,  2,  8,  13,  14,  79,  88,  165, 
166,  168,  170,  174,  177,  364- 
412. 
cerebral,  see  Cerebral  syphilis, 
congenital    or    hereditary,    78, 

168,  178,  196,  400. 
primary,  365,  396,  401. 
prophylaxis  of,  168,  178. 
secondary,  364,  399. 
tertiary,  399. 
Syphilitic  disorders,  194,  364-412, 

630,  631. 
Systematized  delusional  states,  see 
Delusions,  systematized. 

Tabes,  338,  377,  388,  391,  394,  399, 
400,  402,  457,  626,  632. 

Tabetic  form  of  general  paralysis, 
388,  394,  630. 

Tachycardia,  435,  436. 

Taciturnity,  81,  220. 

Tactile  hallucinations,  35,  363. 

Tactlessness,  216. 

Tcedium  vitce,  108,  371. 

Tantrums,  257. 

Tapping  test,  93. 

Taste,  hallucinations  of,  see  Hallu- 
cinations, gustatory. 

Teasing,  269. 

Teeth,  91,  435. 


Temperamental  anomalies,  2,  78, 
79,  90,  200,  202,  215, 303, 639. 
Temperance,  175,  234,  336. 
Temperature,  80,  279,  300,  344, 
345,  360,  385,  419,  423,  426, 
438,  634. 
Temporizing,  257.  ' 

Tenacity,  205. 

Tendon  reflexes,  see  Reflexes,  ten- 
don. 
Tension,  mental,  629. 
Tension,  sexual,  122. 
Terminal    brain    arterioles,    405, 

407,  408,  409. 
Tertiary  syphilis,  399. 
Testamentary  capacity,  xiv,  181, 

182,  183. 
Test,  ammonium  sulphate,  Ross- 
Jones',  89,  391,  459. 
butyric  acid,  Noguchi's,  89,  391, 

459. 
cancelling  A,  621,  623. 
colloidal  gold,  Lange's,  89,  368, 

391,  452,  455-458. 
completion,  Trabue's,  621,  623. 
digit  span,  621,  622. 
Kent-Rosanoff,  547-620. 
logical  memory,  621,  622. 
opposites,  621,  623. 
part-whole,  621,  624. 
phenol,  Pandy's,  89,  391,  459. 
word  building,  621,  624. 
Tests,  association,  90,  97,  98,  547- 
620. 
Binet-Simon,    see   Binet-Simon 

tests, 
chemical,  89,  455-459. 
group,  97,  621-624. 
intelligence,  90,  96. 
psychological,  88,  201,  476-624. 
reading,  85,  375. 
retention,  84. 
serological,  79. 
speech,  81,  375. 
writing,  81,  85. 


682 


INDEX  OF  SUBJECTS 


Tetronal,  106. 
Therapeutic  diversion,  261. 
Therapeutic  occupation,  114,  261. 
Therapeutics,  139,  257,  258.     See 
also       Psychotherapy       and 
Treatment. 
Therapeutics,  educational,  99. 
Thieves,  203. 
Thinking,  autistic,  137-139,  636. 

common  sense,  137-139. 

directed,  137-139. 

dream,  135-139. 

logical,  137-139. 

phantasy,  137-139. 

rational,  137-139. 

two  kinds  of,  137-139. 

vmconscious,  133. 
Thought,  echo  of,  245,  250. 

escape  of,  37. 

flow  of,  81,  91,  98.  See  also 
Distract  ibility.  Disconnected- 
ness, Flight  of  ideas,  and  In- 
coherence. 

repetition  of,  32. 

stealing  of,  32,  245. 
Thought   process,    characteristics 

of,  199. 
Threats,  25. 

Throat,  abnormalities  of,  91. 
Thrombosis,  408. 
Thymus  gland,  634. 
ThjTogenic  psj^choses,   194,  431- 

436,  634,  635. 
Thyroidectomy,  436. 
Thyroid  gland,  431^36. 
ThjToid  medication,  433,  435. 
Thyroidine,  433. 
Timidity,  268,  323,  477,  479. 
Tinnitus  aurium,  382. 
Tired  feeling,  277. 
Tobacco,  355,  356. 
Torpor,  mental,  419,  431,  433,  437. 
Total  mental  content,  120. 
Touch,  hallucinations  of,  35,  363. 
Touchiness,  201. 


Toxic  delirium,  36,  68,  419,  429. 
Toxic  psychoses,  21,  29,  35,  44,  55. 
Trabue's    completion    test,    621, 

623. 
Training,  99,  114,  202,  203,  204, 

212,  258. 
Tramp  life,  227,  639. 
Transference,  121,  136,  140. 
Transformation  of  personality,  see 
Personality,     transformation 
of. 
Transition    forms    of    psychoses, 

100,  260,  636. 
Transitory  delirium,  211. 
Transitory  mania,  211. 
Traumatic    constitution,    9,    194, 
416,  417,  418,  625,  628. 
delirium,  9,  194,  414-416,  625, 

628. 
dementia,  9,  194,  418,  628. 
disorders,  9,  194,  413-418. 
epilepsy,  9,  194,  417,  418,  628. 
hysteria,  301,  308! 
neuroses,  315. 
Traumatism,    78,   256,   257,   308, 
384,  413,  417,  427,  430,  443, 
628,  633.     See  also  Head  in- 
jury. 
Treatment,  76,  80,  86,  91,   118, 
139,  147,  150,  153,  159,  173, 
202,  212,  261,  266,  276,  281, 
282,  289,  299,  306,  308,  334, 
341,  350,  354,  361,  363,  368, 
402,  412,  414,  421,  428,  430, 
432,  433,  435,  436,  448.     See 
also  Psychotherapy  and  Ther- 
apeutics, 
of  excitement,  103. 
of  mental  disorders,  101. 
of  refusal  of  food,  109-112. 
of  suicidal  tendency,  107-109. 
Tremors,  65,  68,  81,  8G,  121,  295, 
300,  309,  337,  344,  360,  374, 
382,  411,  435,  436,  446,  448, 
632,  638. 


INDEX  OF  SUBJECTS 


683 


Tremors,  coarse,  81,  375,  376. 

fibrillary,  375. 

fine,  81. 

intention,  81. 
Treponema    'pallidum,    396,    398, 

399,  401,  461. 
Trional,  106,  436. 
Trophic  disorders,  379,  383. 
Truancy,  148,  191. 
Tube  feeding,  110-112,  241,  298. 

by  the  mouth,  110. 

by  the  nose,  111. 
Tuberculosis,  68,  69,  91,  196,  252, 
299,  341,  354,  361,  385,  394, 
427,  433. 
Tumor,  brain,  see  Brain  tumor. 
Twitching,  muscular,  318, 375,441. 
Typhoid  fever,  346,  421,  427,  634. 
Typhus  fever,  421. 
Typical,  93. 
Tyrannical  tendency,  445. 

Uncertainty,  20,  24,  278,  287,  323, 

424. 
Unclassified  reactions,    550,    551, 

552. 
Unconscious  motives,  121,  314. 
Unconscious,   realm  of  the,    120, 

121,  126,  140,  300. 
Unconscious  thinking,  133. 
Unconscious  wish,  130,  131. 
Unconsciousness,  40,  41,  42,  79, 

206,  208,  414,  415. 
Undercurrent,  257. 
Undernutrition,  318,  634. 
Undesired  idea,  142. 
Uneasiness,    249,    282,    297,    324, 

342,  349,  420,  635. 
Unemployment,  10,  216. 
Ungraded  classes,  192,  202. 
Unilateral  hallucinations,  29. 
Unit  characters,  3. 
Unpleasant     hallucinations,      see 

Hallucinations,  painful  or  un- 
pleasant. 


Unreliability,  125. 
Unrequited  love,  11. 
Unrestrained  persons,  397. 
Unruly  children,  148,  191,  202. 
Untidy  appearance,  81,  243. 
Ursemic  delirium,  429-430. 
Urban      environment,      14,      17, 

401. 
Urine,  64,  65,   69,  81,   234,   294, 

350,  377,  378,  423,  430.     See 

also  Albuminuria. 
Uterine  displacements,  318. 
Utterances,  spontaneous,  81. 

Vagina,  122. 

Vagrancy,  78,  79,  148,  197,  200, 

203,  215. 
Vanity,  262. 
Variola,  421,  634. 
Vasomotor  disorders,    63,  64,  67, 

69,  234,  388,  628. 
Vaso-paralytic  lesions,   395. 
Vegatative  functions,  73. 
Venereal  history,  76,  79. 
Vengeance,  53. 
Ventricles,  brain,  410. 
Verbal  auditory  hallucinations,  31, 

53,  58,  249. 
Verbigeration,    72,   82,   232,   236, 

237,  240,  242,  254. 
Vertigo,   80,  337,  409,  416,  433, 

438. 
epileptic,  206. 
Vice,  185,  190. 
Violence,  42,  220,  359,  389. 
Violent  reactions,  25,  26,  62,  67, 

81,  102,  243,  266,  295,  350, 

363,  387,  429,  637. 
Visceral  disorders,  346,  379,  385, 

394,  432. 
Visceroptosis,  318. 
Visions,  33,  343,  349. 
Visual  hallucinations,  see  Halluci- 

tions,  visual. 
Vital  sense,  73,  74. 


684 


INDEX  OF  SUBJECTS 


Voices,  25,  28,  32,  33,  83, 108, 109, 

297.     See  also  Hallucinations, 

auditory. 
VolubUity,  271,  332,  380. 
Voluntary  commitment,  181,  322. 
Voluntary  reactions,  70,  231,  238. 
Vomiting,  78,  112,  318,  361,  366, 

385,  409,  438,  452,  631,  638. 
Voracious  appetite,  446. 

Wandering  impulse,  227. 
Warm  baths,  104,  105,  299. 
War  neuroses,  303,  304. 
Wassermann    reaction,    89,    178, 

364,  367,  391,  396,  401,  411, 

438,  451,  452,  460-469,  630. 
collecting  specimens  for,  467. 
principle  of,  460. 
reagents  for,  462. 
technique  of,  468. 
Wasting  in  melancholia,  298. 
Watching,  109,  281,  299,  421. 
Waxy  flexibUity,  71,  73. 
Weakness,  muscular,  see  Muscular 

weakness. 
Weapons,  suicidal,  108. 
Weight,  64,  69,  80,  110,  234,  235, 

241,  271,  276,  279,  280,  294, 

324,  360,  361,  377,  378,  381, 

423. 
Wet  pack,  104. 
Whooping  cough,  78. 
Will,  25,  26,  28,  52,  70,  71,  72,  203, 

220,  229,  232,  236,  238,  256, 

300,  336,  342,  424. 


Will,  freedom  of,  xlv,  183,  184. 
paralysis  of,  70,  73. 
perversion  of,  73. 
Wish,  120,  128,  130,  137. 
erotic,  130. 

-fulfilment,  128,  129,  130,  138. 
repressed,  128,  130,  315,  638. 
unconscious,  130,  131. 
Wit,  133. 
Withdrawal  of  alcohol,  347,  348, 

350,  633. 
Withdrawal     of     habit     forming 

drugs,  361,  362. 
Witnesses,  expert,  183. 
Word  building  test,  621,  624. 
Word     complements,     549,    551, 

552. 
Work,  capacity  for,  50,  268,  335, 

373,  408,  417,  633. 
Workhouses,  186. 
World  War,  v,  11,  12,  192,  216, 
218,  300,  304,  318,  347,  436. 
Worms,  intestinal,  91. 
Worrisome    disposition,    78,    79, 

285. 
Worry,  326,  412,  436,  635, 
Writing,  automatic,  37. 
Writing  mediums,  37. 
Writing  tests,  81,  85. 

Yawning,  361. 
Yerkes-Bridges  tests,  96. 

Zoopsia,  337. 


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